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

Association between consumption of non-nutritive sweeteners and gestational diabetes mellitus in Chilean pregnant women: A secondary data analysis of the CHiMINCs-II cohort

OBJECTIVE

To evaluate the association between consumed non-nutritive sweeteners (NNS) and gestational diabetes mellitus (GDM) in a cohort of pregnant women from Santiago, Chile.

METHODS

This secondary data analysis of a cohort.involved 1,472 pregnant women from the Chilean Maternal-Infant Cohort Study-II (CHiMINCs-II). These women received care at primary health care centers in Puente Alto county, South-Eastern Metropolitan Health Service of Santiago, Chile. NNS consumption was estimated using 24-h dietary recalls and linked to the packaged foods nutrition facts panel. Plasma glucose values were extracted from clinical records. GDM was defined according to national criteria: 1) fasting plasma glucose (FPG) ≥100 and <126 mg/dL at the first antenatal visit; 2) FPG ≥100 mg/dL or 2-hour plasma glucose ≥140 mg/dL in the 75 g oral glucose tolerance test at 24-28 weeks. Cases with a GDM diagnosis in their medical records were also considered regardless of test results. The association between each NNS and GDM was assessed using logistic regression models.

RESULTS

A total of 77.8% of the participants consumed NNS. The most consumed was sucralose (66%), followed by acesulfame-K (43.6%), and steviol glycosides (41.1%). Beverages (82%), dairy (12.4%) and candy products (4.4%) were the primary dietary sources of NNS. The GDM incidence was 18.9%, higher among consumers of any NNS compared to non-consumers (20.3% vs. 14.2%, p < 0.05). The adjusted model showed a significant association between the consumption of any NNS and sucralose and the risk of GDM (OR for any NNS = 1.58; 95% CI: 1.10-2.26; P = 0.014; OR sucralose = 1.44; 95% CI 1.06-1.95; P = 0.020).

CONCLUSIONS

The consumption of NNS, particularly sucralose, is associated with an increased risk of GDM in pregnant women. Further studies are essential to validate these results in other contexts and to guide future recommendations for healthier dietary practices among pregnant populations.

Deciphering the multifaceted effects of artificial sweeteners on body health and metabolic functions: a comprehensive review and future perspectives

As the rates of chronic diseases such as obesity and diabetes rise worldwide, there is a growing demand for low-calorie or no-calorie sweeteners to reduce sugar intake without sacrificing the sweetness of foods and beverages. Artificial sweeteners have become indispensable as substitutes for sugar due to their high sweetening power and low impact on blood sugar levels and are used in a variety of low-calorie foods and beverages. Although artificial sweeteners offer an alternative for reducing sugar intake while maintaining sweetness, research into their long-term health effects, particularly at high doses, is ongoing, further scientific research and regulatory review are needed to clarify these potential health risks. This article reviews the latest research on the health effects of artificial sweeteners, based on recent studies, introduces the classification, performance, and safety standards for artificial sweeteners, analyses their potential harms to the nervous, immune, and circulatory systems, reproductive system, as well as their effects on gut microbiota, liver function, cancer, diabetes, and obesity. In addition, consumer perceptions of artificial sweeteners and future research directions are discussed, providing insights into current research controversies and knowledge gaps, as well as the health research and market application of artificial sweeteners.

Sucralose and stevia consumption leads to intergenerational alterations in body weight and intestinal expression of histone deacetylase 3

OBJECTIVES

It is unclear whether parental consumption of non-nutritive sweetener (NNS) can affect subsequent generations. The aim of this study was to determine whether chronic parental consumption of sucralose and stevia in mice affects body weight gain and liver and intestinal expression of histone deacetylase 3 (Hdac3) in these animals and in the subsequent first filial (F1) and second filial (F2) generations.

METHODS

Male and female mice (n = 47) were divided into three groups to receive water alone or supplemented with sucralose (0.1 mg/mL) or stevia (0.1 mg/mL) for 16 wk (parental [F0] generation). F0 mice were bred to produce the F1 generation; then, F1 mice were bred to produce the F2 generation. F1 and F2 animals did not receive NNSs. After euthanasia, hepatic and intestinal expression of Hdac3 was determined by quantitative reverse transcription polymerase chain reaction.

RESULTS

Body weight gain did not differ between the three groups in the F0 generation, but it was greater in the F1 sucralose and stevia groups than in the control group. Consumption of both NNSs in the F0 generation was associated with lower Hdac3 expression in the liver and higher in the intestine. Hepatic Hdac3 expression was normalized to the control values in the F1 and F2 animals of the sucralose and stevia groups. Intestinal expression was still higher in the F1 generations of the sucralose and stevia groups but was partially normalized in the F2 generation of these groups, compared with control.

CONCLUSIONS

NNS consumption differentially affects hepatic and intestinal Hdac3 expression. Changes in hepatic expression are not transmitted to the F1 and F2 generations whereas those in intestinal expression are enhanced in the F1 and attenuated in the F2 generations.

Evolution of household availability of added sugars and their sources in Brazil: analysis of Household Budget Surveys from 2002 to 2017

The objective of this study was to describe the evolution of household purchase of added sugars and their main food sources in Brazil. Nationally representative data from the Household Budget Surveys from 2002-2003, 2008-2009 and 2017-2018 were used. Energy and added sugar quantities were estimated by means of per capita food quantities. The items considered as food sources were: (1) table sugar: refined sugar and other energetic sweeteners and (2) processed and ultra-processed foods with added sugar: soft drinks; other drinks; sweets, candies and chocolates; cookies; cakes and pies and other foods. The parameters estimated were: mean share of added sugar in total energy and, for food sources, the share of added sugar in total sugar intake and the impact of variations in sources of added sugar between 2008 and 2017. There was a regular share of energy from added sugar to total energy intake between 2002 and 2008 but a reduced share in 2017. Between 2008 and 2017, there was a decrease in the share of refined sugar and other sweeteners and soft drinks to total sugar intake and an increased share of all other items. High-income households had a lower share of refined sugar and other energetic sweeteners, but a higher share of soft drinks, sweets, candies and chocolates. The decrease in added sugar in 2017 was mainly due to the lower share of soft drinks. In conclusion, Brazilians' total intake of added sugar was decreased, mostly owing to reduced consumption of sugar from soft drinks.

Effects of front-of-package caffeine and sweetener disclaimers in Mexico: cross-sectional results from the 2020 International Food Policy Study

OBJECTIVE

Front-of-package warning labels introduced in Mexico in 2020 included disclaimers that caution against allowing children to consume products with non-sugary sweeteners and caffeine. We examined the awareness and use of the disclaimers among Mexican adults and youth 1 month after the regulation was implemented. We also investigated their impact on the perceived healthfulness of industrialised beverages designed for children.

DESIGN

Data on the awareness and use of the disclaimers were analysed. Two between-subjects experiments examined the effect of a sweetener disclaimer (Experiment 1, youth and adults) or a caffeine disclaimer (Experiment 2, only adults) on the perceived healthfulness of industrialised beverages. Interactions between experimental conditions and demographic characteristics were tested.

SETTING

Online survey in 2020.

PARTICIPANTS

Mexican adults (≥18 years, n 2108) and youth (10-17 years, n 1790).

RESULTS

Most participants (>80 %) had seen the disclaimers at least rarely, and over 60 % used them sometimes or frequently. The sweetener disclaimer led to a lower perceived healthfulness of a fruit drink (adults: 2·74 ± 1·44; youth: 2·04 ± 0·96) compared with the no-disclaimer condition (adults: 3·17 ± 1·54; youth: 2·32 ± 0·96) (t's: >4·0, P values: <0·001). This effect was larger among older adults and male youth. The caffeine disclaimer did not affect adult's perceived healthfulness of a caffeinated drink (t = 0·861, P value = 0·3894).

CONCLUSIONS

There were high awareness and use of the sweeteners and caffeine disclaimers shortly after the warning labels were implemented. The sweetener disclaimer appears to be helping consumers modify their perceptions regarding industrialised beverages for children. Findings may help decision-makers improve the regulation and better target communication strategies.

Sweeteners in Brazilian processed foods and beverages: prevalence, profile and concomitant addition of sugars and nutritional claims

Brazil is experiencing an increased prevalence of overweight and obesity. To overcome these health problems, several strategies have been implemented, including incentives to reduce sugar intake and new packaging labeling. This has promoted an increase in the use of low or non-caloric sweeteners (LNCS). In this study, the use of LNCS in six Brazilian food groups (non-alcoholic beverages, dairy products, baked goods, confectionery, cereals, and condiments) was investigated through label declarations. Three supermarkets were visited in Belo Horizonte, MG, Brazil. Ten out of the 16 LNCS allowed by the Brazilian legislation were declared. Altogether, among the 441 products included, 17.7% contained at least one LNCS, with an average of 2.21 LNCS per sweetened product. Non-alcoholic beverages (37.2%) and dairy products (29.5%) had the highest LNCS occurrence. Combinations of two, three, four, and seven LNCS were found. Artificial sweeteners represented 87.8% of the declared LNCS, with a higher prevalence of acesulfame-K, followed by cyclamate, and sucralose, respectively. Meanwhile, 53.9% of 78 products containing LNCS also had added sugars, and 70.5% used nutritional claims about reduced sugars and/or calories. This scenario highlights the importance of continuous monitoring of LNCS in foods and beverages as front-of-package labeling is not fully implemented yet.

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.

Position statement on nutrition therapy for overweight and obesity: nutrition department of the Brazilian association for the study of obesity and metabolic syndrome (ABESO-2022)

Obesity is a chronic disease resulting from multifactorial causes mainly related to lifestyle (sedentary lifestyle, inadequate eating habits) and to other conditions such as genetic, hereditary, psychological, cultural, and ethnic factors. The weight loss process is slow and complex, and involves lifestyle changes with an emphasis on nutritional therapy, physical activity practice, psychological interventions, and pharmacological or surgical treatment. Because the management of obesity is a long-term process, it is essential that the nutritional treatment contributes to the maintenance of the individual's global health. The main diet-related causes associated with excess weight are the high consumption of ultraprocessed foods, which are high in fats, sugars, and have high energy density; increased portion sizes; and low intake of fruits, vegetables, and grains. In addition, some situations negatively interfere with the weight loss process, such as fad diets that involve the belief in superfoods, the use of teas and phytotherapics, or even the avoidance of certain food groups, as has currently been the case for foods that are sources of carbohydrates. Individuals with obesity are often exposed to fad diets and, on a recurring basis, adhere to proposals with promises of quick solutions, which are not supported by the scientific literature. The adoption of a dietary pattern combining foods such as grains, lean meats, low-fat dairy, fruits, and vegetables, associated with an energy deficit, is the nutritional treatment recommended by the main international guidelines. Moreover, an emphasis on behavioral aspects including motivational interviewing and the encouragement for the individual to develop skills will contribute to achieve and maintain a healthy weight. Therefore, this Position Statement was prepared based on the analysis of the main randomized controlled studies and meta-analyses that tested different nutrition interventions for weight loss. Topics in the frontier of knowledge such as gut microbiota, inflammation, and nutritional genomics, as well as the processes involved in weight regain, were included in this document. This Position Statement was prepared by the Nutrition Department of the Brazilian Association for the Study of Obesity and Metabolic Syndrome (ABESO), with the collaboration of dietitians from research and clinical fields with an emphasis on strategies for weight loss.

Development and Relative Validation of a Food Frequency Questionnaire to Assess Non-Nutritive Sweeteners Intake among Pregnant Women in Santiago, Chile: A Pilot Study

Studies on the effects of non-nutritive sweeteners (NNSs) among pregnant women are scarce and have produced mixed results. One of the major challenges is to accurately assess NNS intake, especially in countries that have implemented policies to prevent obesity and where many foods and beverages have been progressively reformulated to partially or totally replace sugar with NNSs. This study aimed to develop and assess the relative validity of a food frequency questionnaire (FFQ) for use in pregnant women. We developed an FFQ to examine the intake of seven NNSs (acesulfame-k, aspartame, cyclamate, saccharin, sucralose, steviol glycosides, and D-tagatose). This questionnaire was piloted in 29 pregnant women (median age = 31.2 y; 25th-75th percentile: 26.9-34.7) to assess NNS intake over the previous month, compared to 3-day dietary records (3-DR). The validity of this dietary method was assessed using Spearman's correlation coefficient, Lin´s concordance correlation coefficient (CCC), and Bland-Altman plots. Spearman's correlations between the FFQ on NNSs and 3-DR ranged from 0.50 for acesulfame K to 0.83 for saccharin. CCC ranged between 0.22 and 0.66. The Bland-Altman plots showed an overestimation of saccharin, sucralose, and steviol glycosides intake by the FFQ on NNSs compared with 3-DR, and an underestimation of acesulfame K and aspartame. Overall, the NNSs most frequently consumed were sucralose, and none of the participants exceeded the acceptable daily intake for any of the NNSs evaluated. The FFQ on NNSs seems to be reasonably valid in the assessment of NNSs among pregnant women.

Sweeteners in food samples: An update on pretreatment and analysis techniques since 2015

Sweeteners play an irreplaceable role in daily life and have been found in multitudinous food products. However, excessive or unreasonable intake of sweeteners as food additives brings about untoward problems due to the accumulation in the human body. Therefore, a comprehensive review of different sweeteners' pretreatment and determination methods is urgently needed. In this review, we comprehensively reviewed the progress of different pretreatment and detection methods for sweeteners in various food, focusing on the latest development since 2015. Current state-of-the-art technologies, such as headspace single-drop microextraction, ultrasound-assisted emulsification microextraction, solid-phase microextraction, two-dimensional liquid chromatography, and high-resolution mass spectrometry, are thoroughly discussed. The advantages, disadvantages, critical comments, and future perspectives are also proposed. This review is expected to provide rewarding insights into the future development and broad application of pretreatment and detection methods for sweeteners in different food samples.

Low- and no-calorie sweetener intakes from beverages - an up-to-date assessment in four regions: Brazil, Canada, Mexico and the United States

The current assessment estimated exposure to four low- and no-calorie sweeteners (LNCS) (aspartame, acesulfame potassium (AceK), steviol glycosides and sucralose) from beverages in Brazil, Canada, Mexico and the United States, using up-to-date nationally representative consumption data and industry reported-use level information. Two modelling scenarios were applied - the probabilistic model was guided by reported use level data, with estimated intake for an individual leveraging market-weighted average use level of a particular LNCS in any given LNCS-sweetened beverage type, while the distributional (brand-loyal) model assumed consumer behaviour-led patterns, namely that an individual will be brand loyal to a pre-determined beverage type. Consumer-only and general population intake estimates were derived for the overall population and individual age categories, and compared to the respective acceptable daily intake (ADI) as established by the Joint FAO/WHO Expert Committee on Food Additives (JECFA) for each LNCS. The mean, 90th percentile and 95th percentile intake estimates were substantially lower than the ADI in both modelling scenarios, regardless of the population group or market. In the probabilistic model, the highest consumer-only intake was observed for AceK in Brazilian adolescents (95th percentile, 12.4% of the ADI), while the highest 95th percentile intakes in the distributional model were observed for sucralose in Canadian adults at 20.9% of the ADI. This study provides the latest insights into current intakes of LNCS from water-based non-alcoholic LNCS-sweetened beverages in these regions, aligning well with those published elsewhere.

Perception and knowledge of low- and no-calorie sweeteners in multidisciplinary stakeholders from Spain

Low- and no-calorie sweeteners (LNCS) as a category are one of the most thoroughly evaluated additives, and thus their safety has been largely recognised. However, their potential risks and benefits generate great controversy and discussion within countries' food policies and public debate. The goal of this study was to evaluate the degree of knowledge and the perception of key Spanish stakeholders about the role of LNCS in diet, their safety, regulatory issues and their impact on health and wellness, as well as to complete a SWOT analysis of the Strengths, Weaknesses, Opportunities and Threats regarding this topic from their perspective. Participants (n = 45 stakeholders) completed an anonymous survey about their knowledge and perception of LNCS, their role in the diet, safety and legislation, as well as health issues and completed a SWOT analysis. Most of them agreed with aspects related to safety guarantees and authorisation procedure of LNCS; however, certain disparity in their opinion in relation to several of the topics was observed, especially regarding the possible role of LNCS in diet quality and health. Effective communication strategies to inform professionals and the general population, as well as new research that deepens our knowledge of the role of LNCS in weight management and other health outcomes seem to be urgently needed.

Trend of minimally processed and ultra-processed beverages purchased in Brazilian households: Less milk and much soft drink (2002-2003 to 2017-2018)

The consumption of ultra-processed beverages, including sugar-sweetened and artificially sweetened ones, is associated with several health problems, which is different considering minimally processed beverages. The objective of this study was to assess the trends in the volume of minimally and ultra-processed beverages purchased for consumption in Brazilian households and their relationship with the proportion of dietary energy derived from ultra-processed foods and beverages. Drawing on data from the nationwide 2002-03, 2008-09, and 2017-18 Household Budget Surveys, the daily volume of beverages purchased per capita (milligrams) was investigated. The minimally processed beverages purchased declined over the period [2002-2003: x ¯ 156.5 ml (95%CI: 148.3-164.8); 2017-2018: x ¯ 101.6 ml (95%CI: 98.1-105.1)] and ultra-processed beverages were stable [2002-03: x ¯ 117.9 ml (95%CI: 108.1-127.7); 2017-18: x ¯ 122.8 (95%CI: 111.2-134.4)]. The most purchased beverage in 2002-2003 was milk [ x ¯ : 154.7 ml (95%CI: 146.4-162.9)], while in 2017-2018 regular soft drinks were the most purchased [ x ¯ : 110.7 ml (95%CI: 99.2-122.2)]. There was a decrease in the purchase of whole and skimmed milk and an increase in the purchase of other ultra-processed beverages between the periods. With the increase in the proportion of ultra-processed foods and beverages in the diet, the volume of ultra-processed beverage purchases rose and minimally processed beverages declined. The monitoring of beverage consumption and the implementation of public policies, such as taxation on ultra-processed beverages, are essential to promote improvements in health and curbing non-communicable diseases.

Nutritional Quality of Pre-Packaged Foods in China under Various Nutrient Profile Models

This study used various nutrient profile models (NPMs) to evaluate the nutritional quality of pre-packaged foods in China to inform future food policy development. Nutrition data for pre-packaged foods were collected through FoodSwitch China in 2017-2020. The analyses included 73,885 pre-packaged foods, including 8236 beverages and 65,649 foods. Processed foods (PFs) and ultra-processed foods (UPFs) accounted for 8222 (11.4%) and 47,003 (63.6%) of all products, respectively. Among the 55,425 PFs and UPFs, the overall proportion of products with an excessive quantity of at least one negative nutrient was 86.0% according to the Chilean NPM (2019), 83.3% for the Pan American Health Organization NPM (PAHO NPM), and 90.6% for the Western Pacific Region NPM for protecting children from food marketing (WPHO NPM), respectively. In all NPMs, 70.4% of PFs and UPFs were identified as containing an excessive quantity of at least one negative nutrient, with higher proportions of UPFs compared to PFs. Food groups exceeding nutrient thresholds in most NPMs included snack foods, meat and meat products, bread and bakery products, non-alcoholic beverages, confectionery, and convenience foods. In conclusion, PFs and UPFs accounted for three-fourths of pre-packaged foods in China, and the majority of PFs and UPFs exceeded the threshold for at least one negative nutrient under all three NPMs. Given the need to prevent obesity and other diet-related chronic diseases, efforts are warranted to improve the healthiness of foods in China through evidence-based food policy.

Nutritional Description of Foods with Low- and No-Calorie Sweeteners in Spain: The BADALI Project

The use of low- and no-calorie sweeteners (LNCS) in foods has increased in recent years in response to the negative effects of free sugar on health. However, the health impact of LNCS is still unclear. Studies of the prevalence of LNCS in foods have been published previously, including in Spain. However, the use of health (HCs) and nutrition claims (NCs) to promote these foods and a full nutritional characterization are largely lacking. For this purpose, we used the BADALI database with 4218 foods present in the Spanish market. Our results show that 9.3% of foods have LNCS (including both intense and polyols). Sucralose and acesulfame K were the intense sweeteners most frequently used (52.4% and 48.2%, respectively), whereas maltitol was the preferred polyol (20.3%). Of all foods with LNCS, 30% also had added sugar. Many more foods with LNCS presented HCs and NCs than those without. Sugar was the nutrient most frequently claimed in NCs for LNCS-containing foods, whereas vitamins were for those without these sweeteners. NCs compliance with regulation was similar in both conditions (60.1% for foods without and 63.9% for foods with LNCS). As expected, foods with LNCS had less total sugar content and energy. Surprisingly, the nutrient profile of yogurts with LNCS changed completely: less total and saturated fat, whereas more proteins and sodium. Biscuits with LNCS contained more fibre. The results of our study reveal that the prevalence of LNCS is becoming high in some food types in Spain and that foods containing LNCS are more frequently promoted with HCs/NCs. In addition, it confirms the general reduction in energy and sugar content expected in foods with LNCS. Furthermore, it suggests a reformulation of products beyond sugar content.

Prevalence of low-calorie sweeteners and related front-of-package claims in the Brazilian packaged food supply

BACKGROUND

Low-calorie sweeteners (LCS) are increasingly being used worldwide, including in foods and beverages commonly consumed by children.

OBJECTIVE

To examine the prevalence of LCS in packaged foods and beverages sold in Brazil, whether LCS are added to products with advertising directed to children, and whether foods and beverages with LCS include front-of-package (FoP) LCS-related health and nutrition claims.

DESIGN

Cross-sectional study.

SETTING

A sample (n = 11,434) of packaged foods and beverages sold by the top five largest Brazilian food retailers was examined to identify LCS and added sugars and a subsample (n = 3,491) was examined to determine the presence of advertising directed to children and FoP LCS-related claims in foods and beverages with LCS.

MAIN OUTCOME AND MEASURES

The prevalence of foods and beverages with different types of LCS in the Brazilian food supply, among ultra-processed foods and beverages and among foods and beverages with added sugars were measured. Foods and beverages with advertising directed to children were checked to see if these products had LCS, and how many products with LCS had FoP labels with LCS-related claims.

STATISTICAL ANALYSES

Mean and 95% confidence intervals were used to determine the overall prevalence of foods and beverages with LCS and in the different assessed stratifications.

RESULTS

The prevalence of LCS was 9.3% (95% CI 8.8, 9.9) in Brazilian packaged foods and beverages, 14.6% (95% CI 13.8, 15.4) in ultra-processed products alone, and 5.7% (95% CI 4.2, 7.7) in foods and beverages with advertising directed to children. About 83% of food and beverage with LCS were also sweetened with added sugars. LCS were most frequently added to nonalcoholic sweetened beverages, breakfast cereals, and granola bars. Forty percent of foods and beverages with LCS did not present any front-of-package LCS-related claim.

CONCLUSION

This study shows that LCS are present in 15% of ultra-processed foods and beverages in Brazil, largely used in combination with added sugars, and are found in foods and beverages with advertising directed to children. Clearer FoP information regarding the presence of LCS, in particular in products with advertising directed to children, can help consumers make more informed choices regarding LCS consumption.

The Sharp Rise in the Use of Low- and No-Calorie Sweeteners in Non-Alcoholic Beverages in Slovenia: An Update Based on 2020 Data

Reducing added sugars in non-alcoholic beverages is an important public health goal, which can result in increased use of low- and no-calorie sweeteners (LNCS). The aim of this study was to investigate recent changes in the use of LNCS in non-alcoholic beverages in the Slovenian food supply. The national branded foods dataset was updated with beverages available in 2020, and compared with previous datasets. The data were extracted from food labels. In 2020, N = 1,650 unique beverages were found in shops from five different retailers, covering the majority of the national market. The use of LNCS increased from 13.2% in 2017 and 15.5% in 2019 to 20.2% in 2020, with a major growth in soft drinks (16.8, 19.6, and 26.7%, respectively). We observed a significant growth of beverages containing both LNCS and added sugar. Results were also consistent with sales data, which showed that increased offer of beverages with LNCS also resulted in similarly increased sales of such beverages. The average energy and total sugar content in non-alcoholic beverages decreased, which reflects both the higher percentage of beverages with LNCS, and also the reduction of the sugar content in beverages with only added sugar. Analyses of product-specific reformulation practices highlighted reduced sugar content in 16.8% of products, and in 3.6% with the use of LNCS. The most commonly used LNCS are acesulfame K, sucralose, and aspartame. Typically, combinations are used, however steviol glycosides, sucralose and saccharin are also used alone, in most cases combined with added sugar. The results indicated rapid changes in the use of LNCS in non-alcoholic beverages in the Slovenian food supply, making further monitoring of this area highly relevant.

Changes in the Use of Non-nutritive Sweeteners in the Chilean Food and Beverage Supply After the Implementation of the Food Labeling and Advertising Law

Reductions on the sugars content of the food supply have been described after the initial implementation Chilean Labeling Law, but it is unclear if sugars were replaced by non-caloric sweeteners (NNS). We evaluated changes in the NNSs use in foods and beverages after the initial implementation of the labeling law. We used longitudinal data on packaged foods and beverages collected in six major supermarkets and three candy distributors in Santiago, Chile, in January-February 2015/2016 and in January-February 2017. We included in the analysis beverages, dairy-based beverages, yogurts, breakfast cereals, desserts and ice creams, candies and sweet confectioneries, and sweet spreads with a market share ≥1% of their food groups (n = 999). We compared the use of any NNS, the number of different NNSs used, and the combined use of NNSs and ingredients adding sugars using non-parametric tests for matched samples. We evaluated the association between a reduction in sugars and starting NNS use in the post-implementation period using negative binomial regression. The use of any NNS increased from 37.9 to 43.6% (p < 0.001) after the law's implementation, NNSs increased among beverages, dairy-based beverages, yogurts, and desserts and ice creams (p < 0.05), driven mostly by increases in sucralose and stevia use (p < 0.05). We found that reformulated products that reduced the amount of sugars below the law's cutoff were more likely to start using an NNS in the post-implementation period (prevalence ratio: 12.1; 95%CI: 7.2-20.2; p < 0.001). Our results suggest that NNSs likely replaced sugars after the initial implementation of the law. Further analyses should explore how these changes may impact NNS consumption.

Low- and No-Calorie Sweetener (LNCS) Presence and Consumption among the Portuguese Adult Population

The use of low and no-calorie sweeteners (LNCS) in food and beverages has become increasingly common in the development and reformulation of products to reduce energy derived from added sugars. Our aim was to identify the presence and consumption of LNCS through food and beverages according to consumption patterns in a representative sample (n = 256) of the Portuguese adult population. The study had a descriptive cross-sectional observational design and was based on the application of a Food Frequency Questionnaire. Overall, it was found that 4.1% of the foods and 16.7% of the beverages consumed by the Portuguese adult population contained LNCS. Food groups mostly contributing to LNCS consumption were non-alcoholic beverages such as soft drinks and juices (34.2%); milk and dairy products (16.5%); appetizers such as chips (8.6%); sugars and sweets such as chocolates, candies, or chewing gums (6.1%); meat and derivative products (2.2%); cereals and derivatives (1.2%) and canned fruits (1.2%). Main LNCS consumed were acesulfame-K, sucralose, and aspartame, single or combined, although their prevalence of use differs greatly among foods, beverages, or tabletop sweeteners. In conclusion, LNCS were found across a wide variety of products available in the Portuguese market and their prevalence of inclusion in the diet of the population evidences the need to develop more studies on the evolution of LNCS intake and its impact on the full dietary model and health. Consequently, these food additives should be included in food composition databases and, periodically, updated to reflect the recurrent reformulation strategies adopted by the food industry in its efforts to reduce the energy contribution of added sugars.

Assessment of artificial and natural sweeteners present in packaged non-alcoholic beverages (NABs) sold on the Singapore market

Background

New Nutri-Grade labelling, aimed at reducing Singaporeans’ sugar consumption will be implemented for all pre-packaged non-alcoholic beverages (NABs) sold in retail outlets from end 2021 onwards. It is expected such labelling will have a major impact on sugar content of beverages, as well as the replacement of sugar with non-caloric alternatives.

Methods

This study used product label data obtained from in-store surveys to investigate sugar and sweetener composition of NABs present on the Singapore market. Using this data we calculated products prospective Nutri-Grade classification in order to compare the current market composition with relation to sugar and/or sweetener use.

Results

Over half of the NABs on market were sweetened with sugar (59%) and were associated with less healthy Nutri-Grades of ‘C’ and ‘D’. The use of natural sweeteners; Stevia and Monk fruit, remains low (6%).

Conclusion

With continuous efforts by the government in promoting public health nutrition, it is expected that there will be a greater usage of sugar substitutes among NABs in response to the upcoming implementation of Nutri-Grade and ever-fluctuating consumers’ demands. The data collected in this study provide a point estimate (July–September 2020) on market composition and use of both sugar and artificial sweeteners in beverages prior to integration of the mandatory labelling requirements.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11924-0.

The Influence of Front-of-Package Nutrition Labeling on Consumer Behavior and Product Reformulation

Countries worldwide have implemented mandatory or voluntary front-of-package nutrition labeling systems. We provide a narrative review of (a) real-world evaluations of front-of-package nutrition labels that analyze objective sales data and (b) studies that objectively assess product reformulation in response to a front-of-package nutrition label implementation. We argue that there is sufficient scientific evidence to recommend that governments implement mandatory front-of-package nutrition labeling systems to improve population health. We also present a conceptual framework to describe front-of-package label influence and provide recommendations for the optimal label design, emphasizing that labeling systems should be highly visible and salient, be simple and easy to understand, leverage automatic associations, and integrate informational and emotional messaging. The existing research suggests that Guideline Daily Amount labels should be avoided and that the Health Star Rating and Nutri-Score systems are promising but that systems with warning labels like the one in Chile are likely to produce the largest public health benefits. Expected final online publication date for the Annual Review of Nutrition, Volume 41 is September 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Updated Database and Trends of Declared Low- and No-Calorie Sweeteners From Foods and Beverages Marketed in Spain

Background: The past few years have witnessed an increase in the availability of food products containing one or more low- and no-calorie sweeteners (LNCS) in the Spanish market, mostly due to the new massive reformulation plan. However, these are not included in food composition tables or databases, and, therefore, assessment of their intake among the population is complex. This study aims to update a database including commercialized foods and beverages.

Method: A systematic search of ingredients information from the different food and beverage categories was undertaken during 2019 by recording the availability and type of LNCS declared in the information of the product from labels and online shopping platforms of retailers from Spain to update a previous food composition database compiled in 2017.

Results: A total of 1,238 products were identified. The major groups were sugar and sweets (24%), non-alcoholic beverages (21%), cereals and grains (19%), and milk and dairy products (14%) accounting for >70% of total products. The mainly declared LNCS were sorbitol (19.5%), sucralose (19.5%), and acesulfame K (19.2%).

Conclusion: There is a wide variety of products that include LNCS as a main ingredient with higher availability than when compared with the results of database of 2017, consequently, it might be expected that LNCS are commonly consumed at present in the Spanish diet.

A Fit-for-Purpose Nutrient Profiling Model to Underpin Food and Nutrition Policies in South Africa

South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.

Low- and No-Calorie Sweetener (LNCS) Consumption Patterns Amongst the Spanish Adult Population

Low- and no-calorie sweeteners (LNCS) are a group of food additives characterized by their high sweetness intensity and virtually zero caloric content, attributes that make them potential substitutes for added sugars in processed foods and beverages. However, there is currently scarce information available about both the different LNCS used in food products available in Spain and their consumption patterns. Prompted by these reasons, the aim of this research work was to identify the presence and consumption of LNCS in food and beverages consumed by a representative sample of the Spanish adult population (n = 507). For this purpose, a Food Frequency Questionnaire was carried out. Overall, it was found that 4.5% of the foods and 22.3% of the beverages consumed by the surveyed population contained LNCS. The food groups that presented the highest percentage of daily servings containing LNCS were non-alcoholic beverages such as soft drinks and juices (36.1%); sugars and sweets such as chocolates, candies, or chewing gum (14.2%); milk and dairy products (7.0%); meat and derivative products (5.1%); cereals and derivatives (4.3%); appetizers (1.7%); and, finally, sauces and condiments such as ketchup or mustard (1.0%). The main LNCS consumed were acesulfame-K, sucralose, sorbitol, aspartame, and cyclamate, although their prevalence of use differs greatly among foods, beverages, or tabletop sweeteners. Our results show the great diversity of food groups that are currently including these compounds as ingredients. Consequently, there is a need for these food additives to be included in food composition databases, which should be regularly updated to include LNCS in order to facilitate their assessment and monitoring in dietary nutritional surveys.

Does the Australian Health Star Rating System Encourage Added Sugar Reformulation? Trends in Sweetener Use in Australia

Dietary risk factors, including excess added sugar intake, are leading contributors to Australia's burden of disease. An objective of the Australian Health Star Rating (HSR) system is to encourage the reformulation of packaged foods. Manufacturers may improve a product's HSR by replacing added sugar with non-nutritive sweeteners (NNS). Concerns have been raised regarding the potential substitution effects of ultra-processed foods containing NNS for whole foods, and the long-term impact this may have on population health. The aim of this study was to determine whether the implementation of the HSR system has impacted the use of added sugars and NNS in the food supply. Four product categories were used: products with no added sweetener, products containing added sugar only, products containing NNS only, and products containing a combination of added sugar and NNS. Of 6477 newly released products analyzed displaying a HSR in Australia between 2014-2020, 63% contained added sugars. The proportion of new products sweetened with added sugars increased over time, while NNS use did not, despite a higher average and median HSR for products sweetened with NNS. These findings suggest that at the current time, the HSR system may not discourage the use of added sugars in new products or incentivize the reformulation of added sugar with NNS. As the health risks of NNS are questioned, increased reformulation of products with NNS to reduce the presence of added sugar in the food supply may not address broader health concerns. Instead, supporting the promotion of whole foods and drinks should be prioritized, as well as policy actions that reduce the proliferation and availability of UPFs.

Trends in the Use of Low and No-Calorie Sweeteners in Non-Alcoholic Beverages in Slovenia

Excessive sugar intake and the associated increased obesity risk indicate that food reformulation is needed. Non-alcoholic beverages are often high in free sugars, making reformulation with low and no-calorie sweeteners (LNCS) a common choice. Our knowledge of the use of LNCS in the European food supply is, however, very limited. This study aimed to evaluate the trends in the use of LNCS in different non-alcoholic beverages in the Slovenian food supply over the course of two years. We assessed which LNCS are most used and how the use of LNCS affects energy and sugar content. We analyzed labeling information of non-alcoholic beverages in selected grocery stores, covering the majority of the Slovenian food supply. Selected grocery stores were located in the capital city (Ljubljana). LNCS were present in 13.2% and 15.5% of non-alcoholic beverages in the years 2017 and 2019, respectively. The use of LNCS has significantly increased only in energy drinks (p < 0.01). The most used LNCS in 2017 were acesulfame K, aspartame, and cyclamates. In 2019 the use of sucralose increased significantly (p < 0.01) to become the second most used LNCS. Energy and sugar content varied between subcategories, which depended on the presence of added sugar and LNCS. Comparison between the energy value and the presence of the LNCS showed an almost 50% lower energy content of beverages containing both added sugar and LNCS (E₂₀₁₇ = 92.8 kJ; E₂₀₁₉ = 96.2 kJ per 100 mL), compared with beverages with only added sugar (E₂₀₁₇ = 161.8 kJ; E₂₀₁₉ = 159.0 kJ per 100 mL). In beverages sweetened only with LNCS, the difference was even more noticeable (E₂₀₁₇ = 22.3 kJ; E₂₀₁₉ = 14.3 kJ per 100 mL). Results show that the use of LNCS can help producers reduce the energy value of non-alcoholic beverages. Still, compared to other countries, the offer of such products in the Slovenian food supply is relatively low. However, due to possible public health risks of excessive use of LNCS, producers should be further encouraged for reformulation and production of less sweet products without LNCS, enabling consumers to adapt to less sweet taste of beverages. Further monitoring of LNCS in the food supply is therefore recommended, preferably also with consideration of sales data.

Use of advertising strategies to target children in sugar-sweetened beverages packaging in Mexico and the nutritional quality of those beverages

BACKGROUND

A product package can be a powerful marketing tool to persuade and attract consumers at the point-of-sale. Evidence shows that most advertised products have low nutritional quality. Currently, Mexico has incorporated advertising regulations on food and beverage packaging.

OBJECTIVES

To analyze the advertising strategies used to target children on packaging and to assess the nutritional quality of sugar-sweetened beverages available in the Mexican market.

METHODS

Photographs of 2380 beverages available in retail stores in Mexico City from January to March 2017 were analyzed. Beverages were classified as displaying child-directed strategies or nondirected strategies. Nutrition quality was evaluated using the Pan American Health Organization nutrient profile model.

RESULTS

The use of characters was the most frequent strategy among beverages with child-directed strategies (82.0%). The evaluation of nutrition quality found that 88.0% (P < .001) of sugar-sweetened beverages with child-directed strategies were excessive in free sugars and 56.9% (P < .001) contained other sweeteners. Beverages with more than two advertising strategies have the highest proportion of excessive free sugars (93.4%, 95% CI 82.8-98.6).

CONCLUSIONS

The use of characters and other visual strategies were frequently used in the packaging of sugar-sweetened beverages with child-directed strategies. In addition, these beverages are excessive in free sugars and contain a large number of products with other sweeteners.

The ethics of excise taxes on sugar-sweetened beverages

Sugar-sweetened beverage (SSB) taxation has emerged as a priority policy for promoting health and funding investments in communities most affected by diet-related disease. There are now 8 U.S. jurisdictions and over 40 countries that have implemented SSB taxes. Evaluations show that these policies reduce SSB consumption and purchasing while raising revenues to fund public health, education, and equity. However, there have been few analyses of the ethical considerations of SSB taxation. Using a framework for evaluating the ethics of public health interventions, this paper considers the ethical aspects of SSB excise taxes with respect to: physical health, psychosocial well-being, equality, informed choice, liberty, social and cultural values, and responsibility. Available evidence suggests there is a strong ethical case for levying SSB excise taxes on manufacturers and distributors. SSB excise taxes reduce consumption and purchasing of SSBs and are expected to meaningfully reduce obesity and diet-related morbidity and mortality. Because SSB taxes are specific to a product and its manufacturers, they are unlikely to harm psychosocial health by stigmatizing people who are overweight. SSB excise taxes should lead to greater equality because the health and social benefits are progressive (i.e., low-income individuals are likely to accrue the largest benefits from the tax, even more so when revenues are spent on health and social equity). Meanwhile, the average consumer cost burden that would result if distributors raise SSB prices in reponse to the tax is minimally regressive. Regarding liberty, SSB taxes do not eliminate the option of buying SSBs, but if SSB distributors raise SSB prices, it becomes somewhat more expensive to continue purchasing the same amount of SSBs. Meanwhile, the taxes expand beverage options by funding drinking water availability and prompting industry to expand offerings of unsweetened drinks and SSBs containing less sugar. Furthermore, by averting poor health, SSB taxes should expand overall freedom to pursue one's goals. Informed choice could be facilitated by seeing a higher SSB shelf price (which indicates a drink contains added sugar) and exposure to nutrition education funded with tax revenues. SSB taxation is unlikely to negatively interfere with social or cultural values because taxation would not eliminate having SSBs for special occasions, and SSBs are not a staple of traditional diets. Lastly, SSB taxation attributes responsibility for health in a manner that reflects industry's contribution to obesity and the multisectoral solutions that are needed to prevent diet-related disease.