Sources of Added Sugars Intake Among the U.S. Population: Analysis by Selected Sociodemographic Factors Using the National Health and Nutrition Examination Survey 2011-18

Ketogenic diet but not free-sugar restriction alters glucose tolerance, lipid metabolism, peripheral tissue phenotype, and gut microbiome: RCT

Restricted sugar and ketogenic diets can alter energy balance/metabolism, but decreased energy intake may be compensated by reduced expenditure. In healthy adults, randomization to restricting free sugars or overall carbohydrates (ketogenic diet) for 12 weeks reduces fat mass without changing energy expenditure versus control. Free-sugar restriction minimally affects metabolism or gut microbiome but decreases low-density lipoprotein cholesterol (LDL-C). In contrast, a ketogenic diet decreases glucose tolerance, increases skeletal muscle PDK4, and reduces AMPK and GLUT4 levels. By week 4, the ketogenic diet reduces fasting glucose and increases apolipoprotein B, C-reactive protein, and postprandial glycerol concentrations. However, despite sustained ketosis, these effects are no longer apparent by week 12, when gut microbial beta diversity is altered, possibly reflective of longer-term adjustments to the ketogenic diet and/or energy balance. These data demonstrate that restricting free sugars or overall carbohydrates reduces energy intake without altering physical activity, but with divergent effects on glucose tolerance, lipoprotein profiles, and gut microbiome.

Identifying the Leading Sources of Saturated Fat and Added Sugar in U.S. Adults

The 2020-2025 Dietary Guidelines for Americans recommend limiting intakes of saturated fat and added sugars (SF/AS) to <10% total energy. Data-driven approaches to identify sources of SF/AS are needed to meet these goals. We propose using a population-based approach to identify the leading food and beverage sources of SF/AS consumed by US adults. Foods and beverages reported as consumed were assessed from two, 24 h dietary recalls (24HRDR) from 36,378 adults aged 19 years and older from the 2005-2018 National Health and Nutrition Examination Survey. Intakes of SF/AS were aggregated across both 24HRDR to identify What We Eat in America food categories accounting for ≥90% of SF/AS, respectively, by the total population and within population subgroups. Data were weighted to estimate a nationally representative sample. Ninety-five discrete food categories accounted for ≥90% of the total SF/AS intakes for >88% of the representative sample of U.S. adults. The top sources of SF were cheese, pizza, ice cream, and eggs. The leading sources of AS were soft drinks, tea, fruit drinks, and cakes and pies. This analysis reflects a parsimonious approach to reliably identify foods and beverages that contribute to SF/AS intakes in U.S. adults.

Consumption of foods and beverages rich in added sugar associated with incident metabolic syndrome: the Coronary Artery Risk Development in Young Adults (CARDIA) study

AIMS

Numerous studies report positive associations between total carbohydrate (CHO) intake and incident metabolic syndrome (MetS), but few differentiate quality or type of CHO relative to MetS. We examined source of CHO intake, including added sugar (AS), AS-rich CHO foods, and sugar-sweetened beverages (SSBs) associated with incident MetS in adults enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study.

METHODS AND RESULTS

Among 3154 Black American and White American women and men aged 18-30 years at baseline, dietary intake was assessed by diet history three times over 20 years. Sources of AS-rich CHO foods and beverages include sugar-rich refined grain products, candy, sugar products, and SSBs. Incident MetS was created according to standard criteria. Time-dependent Cox proportional hazards regression analysis evaluated the associations of incident MetS across quintiles of cumulative intakes of AS-rich CHO foods and beverages, AS, and SSBs adjusted for potential confounding factors over 30 years of follow-up. The associations of AS-rich CHO foods and beverages, AS, and SSB intakes with incident MetS were consistent. Compared with the lowest intake, the greatest intakes of AS-rich CHOs, AS, and SSBs were associated with 59% (Ptrend < 0.001), 44% (Ptrend = 0.01), and 34% (Ptrend = 0.03) higher risk of developing MetS, respectively. As expected, diet quality was lower across increasing quintiles of AS-rich CHO foods and beverages, AS, and SSBs (all Ptrend < 0.001).

CONCLUSION

Our study findings are consistent with an elevated risk of developing MetS with greater consumption of AS, AS-rich CHO foods, and SSBs, which support consuming fewer AS-rich CHO foods and SSBs.

Defining Parenting Practices for Reducing Sugar-Sweetened Beverage Consumption Among Preschoolers

While attempts have been made to organize parenting practices in a working system, there are problems that make it difficult to understand how parenting is related to children's eating behaviors. The purpose of this study was to evaluate the validity and reliability of a new instrument evaluating parenting practices toward sugar-sweetened beverages (SSBs) using the nine intervention functions of the Behavior Change Wheel. Each intervention function (education, persuasion, incentivization, coercion, training, restriction, environmental restructuring, modeling, and enablement) was applied to a parenting practice for having a preschooler consume no more than 8 oz of SSBs per week. A survey was developed to evaluate each practice. Forty-eight parents of preschoolers (2-5 years old) completed the survey, and the most utilized practices were modeling, creating a supportive home environment, persuading children, and restricting SSBs. The framework presented in this study can be useful for determining which parenting practices are acceptable and effective for promoting health behaviors among children.

Added sugar intake is associated with weight gain and risk of developing obesity over 30 years: The CARDIA study

BACKGROUND AND AIMS

Numerous prospective studies have examined sugar sweetened beverage (SSB) intake associated with weight gain or incident obesity. Because SSB accounts for only 33 % of added sugar (AS) intake, we investigated the associations of AS intake with change in weight and waist circumference and risk of developing obesity.

METHODS AND RESULTS

At baseline (1985-86) Black and White women and men, aged 18-30 years, enrolled in the Coronary Artery Risk Development in Young Adults (CARDIA) study and were followed for 30 years (2015-16). A diet history assessed dietary intake 3 times over 20 years. Multivariable linear regression evaluated the associations of change in weight (n = 3306) and waist circumference (n = 3296) across quartiles of AS, adjusting for demographics, lifestyle factors, and anthropometrics. Proportional hazards regression analysis evaluated the associations of time-varying cumulative AS intake with risk of incident obesity (n = 4023) and abdominal obesity (n = 3449), adjusting for the same factors. Over 30 years of follow-up, greater AS intake was associated with gaining 2.3 kg more weight (ptrend = 0.01) and 2.2 cm greater change in waist circumference (ptrend = 0.005) as well as increased risk of incident obesity (HR 1.28; 95 % CI: 1.08-1.53) and incident abdominal obesity (HR 1.27; 95 % CI:1.02-1.60).

CONCLUSION

Our findings are consistent with recommendations from the 2020-2025 U S. Dietary Guidelines for Americans to limit daily AS intake.

The Impact and Burden of Dietary Sugars on the Liver

NAFLD, or metabolic dysfunction-associated steatotic liver disease, has increased in prevalence hand in hand with the rise in obesity and increased free sugars in the food supply. The causes of NAFLD are genetic in origin combined with environmental drivers of the disease phenotype. Dietary intake of added sugars has been shown to have a major role in the phenotypic onset and progression of the disease. Simple sugars are key drivers of steatosis, likely through fueling de novo lipogenesis, the conversion of excess carbohydrates into fatty acids, but also appear to upregulate lipogenic metabolism and trigger hyperinsulinemia, another driver. NAFLD carries a clinical burden as it is associated with obesity, type 2 diabetes, metabolic syndrome, and cardiovascular disease. Patient quality of life is also impacted, and there is an enormous economic burden due to healthcare use, which is likely to increase in the coming years. This review aims to discuss the role of dietary sugar in NAFLD pathogenesis, the health and economic burden, and the promising potential of sugar reduction to improve health outcomes for patients with this chronic liver disease.

Micronutrient intake from three popular diet patterns in the United States: modeled replacement of foods highest in added sugar and sodium using the National Health and Nutrition Examination Survey, 2005-2018

Introduction

Fifty-two percent of adults in the United States reported following a popular diet pattern in 2022, yet there is limited information on daily micronutrient intakes associated with these diet patterns. The objective of the present study was to model the impact on micronutrient intake when foods highest in added sugar and sodium were replaced with healthier alternatives to align with the Dietary Guidelines for Americans recommendations.

Methods

Dietary data were acquired from 34,411 adults ≥ 20 y in the National Health and Nutrition Examination Survey, 2005-2018. The National Cancer Institute methodology was used to estimate usual dietary intake at baseline of 17 micronutrients using information from up to two dietary recalls per person. A food substitution model was used to evaluate the impact on micronutrient intake when three servings of foods highest in added sugar and sodium were substituted with healthier alternatives.

Results

Dietary modeling to replace foods highest in added sugar with healthier alternatives increased the mean intake of fat-soluble vitamins (0.15% for vitamin A to 4.28% for vitamin K), most water-soluble vitamins (0.01% for vitamin B1 to 12.09% for vitamin C), and most minerals (0.01% for sodium to 4.44% for potassium) across all diet patterns. Replacing foods highest in sodium had mixed effects on the mean intake of micronutrients. The intake of most fatsoluble vitamins increased by 1.37-6.53% (particularly vitamin A and D), yet while the intake of some water-soluble vitamins and minerals increased by 0.18-2.64% (particularly vitamin B2, calcium, and iron) others decreased by 0.56-10.38% (notably vitamin B3 and B6, magnesium, sodium, and potassium).

Discussion

Modeled replacement of foods highest in added sugar led to more favorable changes in mean micronutrient intake compared to modeled replacement of foods highest in sodium. Due to the composite nature of mixed dishes that include multiple ingredients, food substitutions may result in both favorable and unfavorable changes in micronutrient intake. These findings highlight the challenges of making singleitem food substitutions to increase micronutrient intake and call for further research to evaluate optimal combinations of replacement foods to maximize the intake of all micronutrients simultaneously.

Intakes of Added Sugars, with a Focus on Beverages and the Associations with Nutrient Adequacy in US Adults (NHANES 2003-2018)

The Dietary Guidelines for Americans recommend adults increase their intake of nutrients that are under-consumed while limiting their intake of added sugars, sodium, and saturated fats. The purpose of this study was to examine the relationship between added sugars intake from specific types of beverages with added sugars (soft drinks, fruit drinks, sports and energy drinks, coffee and tea, and flavored milk) and nutrient adequacy among US adults (19+ y). Data from eight consecutive 2-y cycles of NHANES were combined (2003-2004 through 2017-2018), and regression analysis was conducted to test for trends in quantiles of added sugars intake from each beverage source and the rest of the diet (excluding those beverages) and nutrient adequacy. Results revealed significant associations that varied in direction according to the added sugars source, negative for some (i.e., soft drinks) in terms of greater percentages of adults not meeting a defined threshold of nutrient adequacy with higher added sugars intakes, and positive for others (i.e., fruit drinks, flavored milk, the rest of the diet) in terms of lower percentages of adults not meeting nutrient thresholds. In conclusion, the contribution of different added sugars sources to nutrient intakes is a critical consideration in developing population-based dietary recommendations.

Intakes of Added Sugars, with a Focus on Beverages and the Associations with Micronutrient Adequacy in US Children, Adolescents, and Teens (NHANES 2003-2018)

Added sugars intake from sweetened beverages among children, adolescents, and teens is a public health concern. This study examined the relationships between added sugars intake from specific types of beverages with added sugars and from the rest of the diet (excluding beverages with added sugars) and micronutrient adequacy among US children, adolescents, and teens. Data from eight consecutive 2 y cycles of NHANES were combined (2003-04 through 2017-18), and regression analysis was conducted to test for trends in quantiles of added sugars intake from each beverage source (soft drinks, fruit drinks, sport and energy drinks, coffee and tea, and flavored milk) and the rest of the diet (excluding those beverages) and micronutrient adequacy among children (2-8 y) and adolescents and teens (9-18 y). Among those aged 2-8 y, higher added sugars from flavored milk were associated with lower percentages below the estimated average requirement (EAR) for calcium. Among those aged 9-18 y, higher added sugars from soft drinks or coffee and tea were associated with higher percentages below the EAR for magnesium and vitamins A and C. In contrast, higher added sugars from fruit drinks or flavored milk were associated with lower percentages below the EAR (higher percentages above the adequate intake (AI)) for vitamin C (fruit drinks) and calcium, magnesium, phosphorus, vitamin A, and potassium (flavored milk). Regarding the rest of the diet, higher added sugars were associated with lower percentages below the EAR (higher percentages above the AI) for most micronutrients examined. The results suggest that the relationship between added sugars intake and micronutrient adequacy depends on the added sugar sources and their nutrient composition. Continued monitoring of sweetened beverage consumption, including beverage type, and the association with added sugars intake, micronutrient adequacy, and diet quality is warranted, given the changes in consumption and product development over time.

Trends in Loss-Adjusted Availability of Added Sugars and Energy Contribution from Macronutrients and Major Food Groups in Canada and the United States

A clear understanding of changes in the consumption of sugars and other sugars-containing foods has become essential for dietary recommendations and nutrition policy considerations. This study aimed to estimate the consumption trends of added sugars, energy, macronutrients, and food categories using food supply data.

Annual food availability data were obtained from Statistics Canada "Food Available in Canada" database and compared to the equivalent data from Canadian Community Health Survey 2004/2015 and USDA "Food Availability (Per Capita) Data System".

There was a 17% decline in the loss-adjusted per capita consumption of added sugars (%energy) in Canada over the past two decades, largely attributed to reduced intakes of refined sugar and sugars from soft drinks. Added sugars consumption was generally 30% less than that in the US. There was also a consistent decline in total energy intake and %energy from carbohydrates, accompanied by increased %energy derived from fats particularly during the most recent 10 years.

The observed trends in added sugars availability are similar to findings from the Canadian Community Health Surveys, demonstrating the potential application of annual loss-adjusted food availability data in monitoring trends in food and macronutrient intakes over time to complement dietary survey data in informing public policy development.

Factors associated with added sugar consumption of older adults from the region of Campinas-SP, Brazil

Adequate nutrition has a profound impact on older adults' health. Therefore, special attention should be given to the dietetic intake of added sugars, which in excess is associated with poorer control of chronic diseases in this phase. The aim of the study was to evaluate the prevalence of consumption of added sugars in older adults in the Campinas-SP region, its associated factors, and its main dietary sources. A cross-sectional study was conducted in the region of Campinas-SP, with a convenience sample of 586 older individuals. Intake was obtained using two 24-hour food recalls, and values >5% of total energy consumption were considered inadequate. The contribution of the groups and foods in relation to the total content of sugars was also calculated. A critical level of p<0.05 was considered. The average intake of added sugars was higher than recommended (7.0%), and this inadequacy was observed in more than half of the sample, being table sugar and honey the main dietary sources. The prevalence of inadequate consumption was higher among women (69.8%; p=0.004) and individuals with low weight (83.7%; p=0.014), and lower in those with diabetes (47.8%; p<0.001). Results indicate that health and nutrition actions should be developed to ensure adequate sugar intake at this stage.

Restricting sugar or carbohydrate intake does not impact physical activity level or energy intake over 24 h despite changes in substrate use: a randomised crossover study in healthy men and women

PURPOSE

To determine the effects of dietary sugar or carbohydrate restriction on physical activity energy expenditure, energy intake, and physiological outcomes across 24 h.

METHODS

In a randomized, open-label crossover design, twenty-five healthy men (n = 10) and women (n = 15) consumed three diets over a 24-h period: moderate carbohydrate and sugar content (MODSUG = 50% carbohydrate [20% sugars], 15% protein, 35% fat); low sugar content (LOWSUG = 50% carbohydrate [< 5% sugars], 15% protein, 35% fat); and low carbohydrate content (LOWCHO = 8% carbohydrate [< 5% sugars], 15% protein, 77% fat). Postprandial metabolic responses to a prescribed breakfast (20% EI) were monitored under laboratory conditions before an ad libitum test lunch, with subsequent diet and physical activity monitoring under free-living conditions until blood sample collection the following morning.

RESULTS

The MODSUG, LOWSUG and LOWCHO diets resulted in similar mean [95%CI] rates of both physical activity energy expenditure (771 [624, 919] vs. 677 [565, 789] vs. 802 [614, 991] kcal·d-1; p = 0.29] and energy intake (2071 [1794, 2347] vs. 2195 [1918, 2473] vs. 2194 [1890, 2498] kcal·d-1; P = 0.34), respectively. The LOWCHO condition elicited the lowest glycaemic and insulinaemic responses to breakfast (P < 0.01) but the highest 24-h increase in LDL-cholesterol concentrations (P < 0.001), with no differences between the MODSUG and LOWSUG treatments. Leptin concentrations decreased over 24-h of consuming LOWCHO relative to LOWSUG (p < 0.01).

CONCLUSION

When energy density is controlled for, restricting either sugar or total dietary carbohydrate does not modulate physical activity level or energy intake over a 24-h period (~ 19-h free-living) despite substantial metabolic changes.

CLINICAL TRIALS REGISTRATION ID

NCT03509610, https://clinicaltrials.gov/show/NCT03509610.

High Added Sugars Intake among US Adults: Characteristics, Eating Occasions, and Top Sources, 2015-2018

The 2020−2025 Dietary Guidelines for Americans (DGA) recommends less than 10% of total daily calories come from added sugars. However, many adults overconsume added sugars putting them at risk for poor health outcomes. We examined characteristics of high added sugars consumers among US adults (≥20 years) and described their top 10 sources of added sugars intake using National Health and Nutrition Examination Survey 2015−2018 data (n = 9647). We defined high consumers as consuming >15% of daily calories from added sugars (1.5 times higher than the DGA). We used the National Cancer Institute method to estimate usual intake of energy and percent of calories from added sugars. Top 10 sources were identified based on their percentage contribution to total added sugars intake on a given day. T-tests were used to examine differences by age, sex, race/ethnicity, education, income, marital status, and weight status. Overall, mean usual total energy intake and added sugars intake was 2068 kcal/day and 264 kcal/day, respectively, and 30% of adults were classified as high consumers. The prevalence of high added sugars consumers was significantly higher among 20−30-year-olds (29%), 31−50-year-olds (33%), and 51−70-year-olds (29%) than those aged ≥70 years (22%); non-Hispanic Black (39%) and non-Hispanic White (31%) adults than Hispanics (26%); adults with <high school (37%), high school/GED (38%), or some college (34%) than adults with college or higher (15%); adults living in lower-income households (39% for federal poverty income ratio < 130% and 35% for 130%−<350%) than high-income households (21%). The prevalence of high consumers did not differ by sex or weight status. Top sources of added sugars were sweetened beverages (42%), tea (12%), sweet bakery products (11%), and jams/syrups/sugars (7%). Our findings can inform intervention efforts to decrease added sugars intake to support health.

Use of a Water Filter at Home Reduces Sugary Drink Consumption among Parents and Infants/Toddlers in a Predominantly Hispanic Community: Results from the Water Up!@ Home Intervention Trial

BACKGROUND

Water is recommended as an alternative for sugar-sweetened beverages (SSBs). Low-income, minority groups in the United States continue to exhibit high SSB and low water consumption, and are more likely to exceed 100% fruit juice recommendations.

OBJECTIVE

To test the effects of a home-based intervention designed to replace SSBs with tap water and reduce excess juice consumption among parents and their infants/toddlers.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Parents (n = 92) of infants/toddlers who participated in three Early Head Start home-visiting programs that serve predominantly Hispanic, low-income communities during 2019-2021.

INTERVENTION

The 12-week intervention (Water Up!@Home) simultaneously addressed physical barriers to tap water consumption (via a water filter) and sociocultural barriers to replacing SSBs and juice with water (via a curriculum). Comparison group received a water filter only. We hypothesized that the intervention would lead to a reduction of 6 fl oz/d in SSB and juice consumption.

MAIN OUTCOMES

Parent-reported self and infant/toddler SSBs, water (filtered, tap, or bottled), and 100% fruit juice consumption.

STATISTICAL ANALYSES

Analysis of covariance to compare changes in consumption between experimental groups was performed. We also conducted t tests to assess changes within groups.

RESULTS

Participants in both groups reported significant reductions in SSBs from baseline (parents: intervention [-11.2 fl oz/d; P < 0.01]; comparison [-8.0 fl oz/d; P < 0.01]; children: intervention [-1.50 fl oz/d; P = 0.03]; comparison [-1.56 fl oz/d; P = 0.02]), increased water consumption (parents in both groups [+5.6 fl oz/d]; children: intervention [+3.61 fl oz/d; P = 0.01], comparison [+2.24 fl oz/d; P = 0.05]), mostly from filtered tap water. Differences between groups were not statistically significant. Intervention participants reported significant reductions in 100% fruit juice vs comparison (parents: -3.6 fl oz/d vs -1.0 fl oz/d; P < 0.01; children: -0.73 fl oz/d vs +0.48 fl oz/d; P = .03).

CONCLUSIONS

The intervention effectively reduced 100% fruit juice consumption. Water security should be examined as a contributor to SSB consumption in this population.

Trends in Diet Quality by Race/Ethnicity among Adults in the United States for 2011-2018

This study aimed to investigate time trends in diet quality and the consumption of major food groups and nutrients by race/ethnicity among adults in the United States. Dietary data from 19,192 adults aged ≥ 20 years from four National Health and Nutrition Survey (NHANES) cycles (2011-2018) were included. The Healthy Eating Index (HEI) 2015 scores (range: 0-100; higher scores indicate better diet quality) and dietary consumption of food groups and nutrients were estimated for each cycle. Linear regression was used to test trends. For the overall population, the estimated overall HEI-2015 scores significantly decreased (p for trend = 0.011). However, decreases were observed in the estimated consumption of added sugars and total carbohydrates, while the estimated consumption of soy products and polyunsaturated fatty acids was significantly increased. A significant decrease in overall HEI-2015 score was observed in the non-Hispanic white group, but not in other racial/ethnic groups. Decreases in added sugar intake were found in the non-Hispanic black and Hispanic groups; sodium intake significantly decreased in the non-Hispanic Asian group. From 2011 to 2018, there was a decrease in estimated overall diet quality in US adults; however, there were improvements in certain nutrients and dietary components. Nevertheless, disparities in diet quality exist among racial/ethnic groups.

Effect of Front-of-Package Information, Fruit Imagery, and High-Added Sugar Warning Labels on Parent Beverage Choices for Children: A Randomized Clinical Trial

IMPORTANCE

Fruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior.

OBJECTIVE

To assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high-added sugar warnings on parents' choices, knowledge, and perceptions of beverages.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US.

INTERVENTIONS

Participants were shown no-, low-, and high-added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high-added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure.

MAIN OUTCOMES AND MEASURES

Primary outcomes were type of beverage chosen (eg, high-added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions.

RESULTS

There were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (-1.3 g; 95% CI, -2.6 to -0.1 g [-14.2%; 95% CI, -26.7% to -1.8%]; P = .04) and calories (-5.3 kcal; 95% CI, -9.8 to -0.9 kcal [-6.5%; 95% CI, -11.8% to -1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high-added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high-added sugar beverages (-7.6 percentage points; 95% CI, -12.6 to -2.6 percentage points [-18.4%; 95% CI, -30.6% to -6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice.

CONCLUSIONS AND RELEVANCE

These findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents' purchases of high-added sugar beverages for their young children but that percentage juice disclosures may not change behavior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04811690.

Added sugar intake and its forms and sources in relation to risk of non-alcoholic fatty liver disease: results from the Tianjin Chronic Low-grade Systemic Inflammation and Health cohort study

It has been suggested that added sugar intake is associated with non-alcoholic fatty liver disease (NAFLD). However, previous studies only focused on sugar-sweetened beverages; the evidence for associations with total added sugars and their sources is scarce. This study aimed to examine the associations of total added sugars, their physical forms (liquid v. solid) and food sources with risk of NAFLD among adults in Tianjin, China. We used data from 15 538 participants, free of NAFLD, other liver diseases, CVD, cancer or diabetes at baseline (2013-2018 years). Added sugar intake was estimated from a validated 100-item FFQ. NAFLD was diagnosed by ultrasonography after exclusion of other causes of liver diseases. Multivariable Cox proportional hazards models were fitted to calculate hazard ratios (HR) and corresponding 95 % CI for NAFLD risk with added sugar intake. During a median follow-up of 4·2 years, 3476 incident NAFLD cases were documented. After adjusting for age, sex, BMI and its change from baseline to follow-up, lifestyle factors, personal and family medical history and overall diet quality, the multivariable HR of NAFLD risk were 1·18 (95 % CI 1·06, 1·32) for total added sugars, 1·20 (95 % CI 1·08, 1·33) for liquid added sugars and 0·96 (95 % CI 0·86, 1·07) for solid added sugars when comparing the highest quartiles of intake with the lowest quartiles of intake. In this prospective cohort of Chinese adults, higher intakes of total added sugars and liquid added sugars, but not solid added sugars, were associated with a higher risk of NAFLD.

Assessment of Calories Purchased After Calorie Labeling of Prepared Foods in a Large Supermarket Chain

IMPORTANCE

Calorie labels for prepared (ie, ready-to-eat) foods are required in large chain food establishments in the US. Large evaluations in restaurants suggest small declines in purchases of prepared foods after labeling, but to the authors' knowledge, no studies have examined how this policy influences supermarket purchases.

OBJECTIVE

To estimate changes in calories purchased from prepared foods and potential packaged substitutes compared with control foods after calorie labeling of prepared foods in supermarkets.

DESIGN, SETTING, AND PARTICIPANTS

This controlled interrupted time series compared sales 2 years before labeling implementation (April 2015-April 2017) with sales 7 months after labeling implementation (May 2017-December 2017). Data from 173 supermarkets from a supermarket chain with locations in Maine, Massachusetts, New Hampshire, New York, and Vermont were analyzed from March 2020 to May 2022.

INTERVENTION

Implementation of calorie labeling of prepared foods in April 2017.

MAIN OUTCOMES AND MEASURES

Purchased items were classified as prepared foods, potential packaged substitutes for prepared foods, or all other (ie, control) foods. The primary outcome was mean weekly calories per transaction purchased from prepared foods, and the secondary outcome was mean weekly calories per transaction purchased from similar packaged items (for substitution analyses). Analyses of prepared and packaged foods were stratified by food category (bakery, entrées and sides, or deli meats and cheeses).

RESULTS

Among the included 173 supermarkets, calorie labeling was associated with a mean 5.1% decrease (95% CI, -5.8% to -4.4%) in calories per transaction purchased from prepared bakery items and an 11.0% decrease (95% CI, -11.9% to -10.1%) from prepared deli items, adjusted for changes in control foods; no changes were observed for prepared entrées and sides (change = 0.3%; 95% CI, -2.5% to 3.0%). Labeling was also associated with decreased calories per transaction purchased from packaged bakery items (change = -3.9%; 95% CI, -4.3% to -3.6%), packaged entrées and sides (change = -1.2%; 95% CI, -1.4% to -0.9%), and packaged deli items (change = -2.1%; 95% CI, -2.4% to -1.7%).

CONCLUSIONS AND RELEVANCE

In this longitudinal study of supermarkets, calorie labeling of prepared foods was associated with small to moderate decreases in calories purchased from prepared bakery and deli items without evidence of substitution to similar packaged foods.

Trends in added sugars intake and sources among U.S. adults using the National Health and Nutrition Examination Survey (NHANES) 2001–2018

Research on trends over time in added sugars intake is important to help gain insights into how population intakes change with evolving dietary guidelines and policies on reducing added sugars. The purpose of this study was to provide an analysis of dietary trends in added sugars intakes and sources among U.S. adults from 2001 to 2018, with a focus on variations according to the sociodemographic factors, age, sex, race and ethnicity and income, and the health-related factors, physical activity and body weight. Data from nine consecutive 2 year cycles of the National Health and Nutrition Examination Survey (NHANES) were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001 to 2018. Trends were examined in the whole sample (19+ years) and in subsamples stratified by age (19–50, 51+ years), sex, race and ethnicity (Asian, Black, Hispanic, White), household income (poverty income ratio low, medium, high), physical activity level (sedentary, moderate, vigorous) and body weight status (normal, overweight, obese). From 2001 to 2018, added sugars intake (% kcal) decreased significantly (P &lt; 0.01), from 16.2 to 12.7% among younger adults (19–50 years), mainly due to declines in added sugars from sweetened beverages, which remained the top source. There were no changes in intake among older adults, and by 2018, the 23% difference in intake between younger and older adults that existed in 2001 almost disappeared. Declines in added sugars intake were similar among Black and White individuals, and all income, physical activity and body weight groups. Population-wide reductions in added sugars intake among younger adults over an 18 year time span coincide with the increasing public health focus on reducing added sugars intake. With the updated Nutrition Facts label now displaying added sugars content, it remains to be seen how added sugars intake trends carry forward in the future.

The Effect of Steviol Glycosides on Sensory Properties and Acceptability of Ice Cream

There has been a challenge in overcoming the bitter aftertaste of stevia, a natural non-caloric sweetener. Recent research focuses on investigating various types of steviol glycosides, the sweet compounds in stevia leaves, as they exhibit different sensory characteristics. This study determined the sensory properties and acceptability of ice cream sweetened solely with three steviol glycosides, rebaudioside (Reb) A, D, and M (0.09% w/v), using sucrose-sweetened ice cream as a control (14% w/v). Ice cream consumers (n = 92) rated their overall liking, attribute liking, and sweetness and bitterness intensities and described the aftertastes of each sample using check-all-that-apply. The liking scores of Reb D- and M-sweetened ice creams were significantly higher than those of Reb A-sweetened ice cream. Among the three glycosides, only Reb M showed a sweetness intensity comparable with that of sucrose. Consumers perceived the aftertastes of Reb D and M ice creams as being more sweet, pleasant, creamy, and milky, while Reb A was more artificial and chemical. Reb D and M ice creams were also plotted close to sucrose in the correspondence analysis graph, meaning that their aftertaste characteristics were similar to those of sucrose. The present study clearly highlights that Reb D and M have better tastes and provide better perceptions to consumers than Reb A, which is the most widely used glycoside in food industry.

How have media campaigns been used to promote and discourage healthy and unhealthy beverages in the United States? A systematic scoping review to inform future research to reduce sugary beverage health risks

Sugary beverage consumption is associated with many health risks. This study used a proof-of-concept media campaign typology to examine U.S. beverage campaigns that promoted healthy beverages and encouraged or discouraged sugary beverages. We used a three-step systematic scoping review to identify, organize, analyze, and synthesize evidence. Step 1 used Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines to search four electronic databases and gray literature through 2021. Step 2 categorized relevant media campaigns using a media campaign typology. Step 3 examined campaign evaluation outcomes. We identified 280 campaigns organized into six campaign typology categories. The media landscape was dominated by corporate marketing campaigns for branded sugary beverages (65.8%; n = 184) followed by public awareness (9.6%; n = 27), public policy (8.2%; n = 23), social marketing (7.1%; n = 20), corporate social responsibility (5.7%; n = 16), and countermarketing (3.6%; n = 10) campaigns. Evaluations for 20 unique campaigns implemented over 30 years (1992-2021) across 14 states showed reduced sugary beverage or juice and increased water or low-fat milk sales and intake. Positive short-term cognitive and mid-term retail and behavioral changes were reported. There was limited evidence for long-term policy, social norm, and population health outcomes. Future research is needed to use media campaigns in strategic communications to reduce sugary beverage health risks for Americans.

Protocol: Effectiveness of message content and format on individual and collective efficacy in reducing the intention to consume sugar-sweetened beverages

The strategic use of media is a common approach to promote health. A large body of evidence identifies specific features that increase message efficacy, including tailoring messages to the target audience and using a storytelling format. Yet most message testing research has focused on individual-level outcomes, ignoring the social and environmental determinants of health behaviors, which require collective action and political will to change. Grounded in an ecological approach to communication, we will carry out two double-blinded randomized experiments to test the relative effectiveness of message tailoring (culturally-tailored vs. standard) and format (narrative vs. didactic) to increase the intention to reduce individual sugar-sweetened beverage consumption, the understanding of social and commercial determinants of health, and the sense of empowerment among young adult Latinas. Based on power analyses (80% power at alpha = 0.05), we will randomize 438 participants to two groups (traditional standard infographic and culturally-tailored infographic) in the first study, and 662 participants to two groups (culturally-tailored infographic and culturally-tailored comic book) in the second study. All participants will be measured by a pre-treatment test and an immediate post-treatment test. We hypothesize that culturally-tailored comic book will be most effective, and traditional standard infographic will be least effective, on all levels of outcomes. This study will provide empirical evidence in communication strategies to help young Latinos or other racial/ethnic minority young people to pursue positive dietary behaviors that both benefit themselves and contribute to change of social norms.

Ultra-processed foods and total sugars intake in Korea: evidence from the Korea National Health and Nutrition Examination Survey 2016–2018

BACKGROUND/OBJECTIVES

Dietary sugars intake worldwide is stable or decreasing, but overall sugars intake remains above the recommended level. Some studies suggest that ultra-processed foods (UPFs) drive excessive sugars intake. However, UPF consumption in Korea and its association with sugars intake have not yet been studied. This study aimed to estimate the contribution of UPF consumption to total sugars intake and to investigate the association between UPF consumption and total sugars intake in Koreans.

SUBJECTS/METHODS

Data from the Korea National Health and Nutrition Examination Survey 2016–2018 were used, and included data on 21,075 participants aged 1+ years completed a 24-h recall. Food items reported in the 24-h recall were classified according to the NOVA system as UPFs, processed foods, processed culinary ingredients, or unprocessed or minimally processed foods.

RESULTS

The average daily energy intake was 1,996 kcal, and UPFs accounted for 26.2% of the total energy intake (% TE). The average total sugars intake was 63.1 g (13.0% TE), and 44.9% of total sugars intake came from UPFs. Among the entire population, 15.8% exceeded the recommended limit for total sugars within 20% TE, and excessive total sugars intake was more prevalent among females (19.5%) and children (21.1%). The prevalence of excessive total sugars intake showed a significantly increasing tendency across the quartiles of UPF energy contribution, ranging from 11.9% in the lowest quartile to 23.2% in the highest quartile. Even after adjustment for sociodemographic variables, UPF consumption was positively associated with the prevalence of excessive total sugars intake (P for trend < 0.001). This association was similar in subgroup analyses by sex and age.

CONCLUSIONS

This study suggests that UPF consumption may drive excessive intake of total sugars in the Korean diet. Our findings conclusively establish that restricting UPF consumption may be an efficient way to reduce sugars intake in Korean population.

Trends in Added Sugars Intake and Sources Among US Children, Adolescents, and Teens Using NHANES 2001-2018

BACKGROUND

Over the past 2 decades, there has been an increased emphasis on added sugars intake in the Dietary Guidelines for Americans (DGA), which has been accompanied by policies and interventions aimed at reducing intake, particularly among children, adolescents, and teens.

OBJECTIVES

The present study provides a comprehensive time-trends analysis of added sugars intakes and contributing sources in the diets of US children, adolescents, and teens (2-18 years) from 2001-2018, focusing on variations according to sociodemographic factors (age, sex, race and ethnicity, income), food assistance, and health-related factors (physical activity level, body weight status).

METHODS

Data from 9 consecutive 2-year cycles of the NHANES were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001-2018 for the overall age group (2-18 years) and for 2 age subgroups (2-8 and 9-18 years). Trends were also examined on subsamples stratified by sex, race and ethnicity (Hispanic, non-Hispanic Asian, non-Hispanic Black, non-Hispanic White), income (household poverty income ratio), food assistance, physical activity level, and body weight status.

RESULTS

From 2001-2018, added sugars intakes decreased significantly (P < 0.01), from 15.6% to 12.6% kcal among children (2-8 years) and from 18.4% to 14.3% kcal among adolescents and teens (9-18 years), mainly due to significant declines in added sugars from sweetened beverages, which remained the top source. Declines in added sugars intakes were observed for all strata, albeit to varying degrees.

CONCLUSIONS

Declines in added sugars intakes were observed among children, adolescents, and teens from 2001-2018, regardless of sociodemographic factors, food assistance, physical activity level, or body weight status, but variations in the magnitudes of decline suggest persistent disparities related to race and ethnicity and to income. Despite these declines, intakes remain above the DGA recommendation; thus, continued monitoring is warranted.