The Effect of Non-Nutritive Sweetened Beverages on Postprandial Glycemic and Endocrine Responses: A Systematic Review and Network Meta-Analysis

Association between low-calorie sweetener consumption during pregnancy and child health: A systematic review and meta-analysis

We examined the association between low-calorie sweeteners (LCS) consumption during preconception, pregnancy, and breastfeeding and child health outcomes. A systematic search of electronic databases in PubMed, Embase, Cumulated Index to Nursing and Allied Health Literature, the Cochrane Library, Scopus, Web of Science, PsycINFO, ProQuest Health and Medical, ClinicalTrials.gov, and Google Scholar was conducted up to 21 September 2023. A random effects model with restricted maximum likelihood estimation was used for the meta-analysis. Seventeen eligible studies were included. The standardised mean difference (SMD) and 95% confidence interval (CI) in birth weight between those who frequently consumed LCS (≥1 serve/day) during pregnancy and those who did not consume LCS was 0.04 (0.00, 0.08) (four cohort studies). Any LCS consumption during pregnancy compared with no consumption was not associated with birth weight [SMD (95% CI) = 0.03 (-0.03, 0.08)] (four cohort studies). Any LCS consumption during pregnancy was not associated with body mass index z-scores. The weighted mean difference (95% CI) was 0.00 (-0.05, 0.06) at birth, 0.06 (-0.29, 0.40) at 6 months, -0.04 (-0.19, 0.10) at 1 year, 0.00 (-0.16, 0.17) at 3 years, and 0.10 (-0.15, 0.34) at 7 years of the child age, compared with no intake (five cohort studies). The odds of being overweight at 1 year among children exposed to LCS during pregnancy was 1.19 (OR [95% CI]: 1.19 [0.81, 1.58]) compared with unexposed children (two cohort studies). The effect sizes were not precise for all the outcomes as the 95% CI indicated the effect estimates could range from small protective to a higher risk. The effect of LCS consumption on child behaviour and cognition was inconsistent. There is not enough evidence to confirm LCS consumption during pregnancy affects birth weight and risk of overweight in children. However, frequent consumption increased birth weight and the risk of overweight at different ages, though the effects were imprecise. More robust research evidence is required as the quality of evidence is low.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The effects of non-nutritive sweeteners on energy and macronutrients intake in adults: a grade-assessed systematic review and meta-analyses of randomized controlled trials

Objectives

The effect of non-nutritive sweeteners (NNSs) on long-term satiety is not well understood. This systematic review and meta-analysis were performed to investigate the effect of NNSs on long-term total energy and macronutrients intake.

Methods

Online databases including Scopus, PubMed, ISI Web of Science, and Google Scholar were searched up to September 2024 to find relevant randomized control trials (RCTs). A random effects model was used for estimating the overall effects.

Results

The results showed a reducing effect of NNSs consumption vs. sugar on total energy intake [total energy intake change = -175.26 kcal/day, 95% confidence interval (CI): -296.47 to -54.06, I2 = 61.19%] and carbohydrate intake [Hedges' g = -0.35, 95% CI: -0.63 to -0.06, I2 = 58.99%]. While, NNSs intake vs. water was not associated with significant change in total energy intake [total energy intake change = 29.94 kcal/day, 95% CI: -70.37 to 130.24, I2 = 34.98%] and carbohydrate intake [Hedges' g = 0.28, 95% CI: -0.02 to 0.58, I2 = 65.26%]. The Consumption of NNSs compared to the either sugar or water did not have a significant effect on fat intake [Hedges' g sugar = 0.08, 95% CI: -0.10 to 0.26, I2 = 8.73%/ fat intake change water = 0.20 g/day, 95% CI: -3.48 to 3.88, I2 = 0%] and Protein intake [Hedges' g sugar = 0.16, 95% CI: -0.11 to 0.42, I 2  = 50.83%/Hedges' g water = 0.00, 95% CI: -0.15 to 0.16, I2 = 0%].

Conclusion

In summary, our findings suggest that NNSs consumption may be effective in reducing total energy and carbohydrate intake compared to sugar.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=432816, CRD42023432816.

Sugar-sweetened beverages, low/no-calorie beverages, fruit juices intake and risks of metabolic syndrome in adults: The SWEET project

BACKGROUND AND AIMS

Metabolic syndrome (MetS) is an important determinant of cardiometabolic disease development, with excessive sugar intake as one of the key modifiable risk factors. However, evidence on the association between sugar-sweetened beverages (SSB), their replacement by low/no caloric beverages (LNCB), and MetS development is still limited.

METHODS AND RESULTS

Data from participants' of Lifelines (n = 58 220), NQPlus (n = 1094) and Feel4Diabetes (n = 342) were prospectively analysed. Dose-response associations were investigated using restricted cubic spline analyses (Lifelines). Cox proportional hazard regression analysis with robust variance was used to quantify associations between intakes of SSB, fruit juices (FJ) and LNCB and MetS incidence; data were pooled using random-effects models. Associations were adjusted for demographic, lifestyle and other dietary factors. In Lifelines, NQPlus, and Feel4Diabetes, 3853 (7 %), 47 (4 %), and 39 (11 %) participants developed MetS, respectively. Pooled analyses showed that each additional serving of SSB was associated with a 6 % higher risk of MetS (95%CI 1.02-1.10). A J-shaped association was observed for FJ and MetS, with a significant inverse association at moderate intake levels (IPR 0.89, 95 % CI 0.82-0.96). LNCB intake was not associated with MetS (IPR 1.59, 95%CI 0.74-2.43), but findings across studies were inconsistent (I2 94 %, p-value <0.01). Replacing SSB with FJ or LNCB did not show any associations with MetS incidence.

CONCLUSION

SSB intake was adversely associated with MetS incidence. A J-shaped association was observed between FJ and MetS. For LNCB, results were inconsistent across studies and therefore findings must be interpreted cautiously.

Impact of Some Natural and Artificial Sweeteners Consumption on Different Hormonal Levels and Inflammatory Cytokines in Male Rats: In Vivo and In Silico Studies

Substituting sugar with noncaloric sweeteners prevents overweight and diabetes development. They come in two types: artificial, like aspartame and sucralose, and natural, such as sorbitol. This research aimed to assess the effects of sucrose and these sweeteners on nutritional parameters, hematological parameters, hormones, and anti- and pro-inflammatory cytokines in male rats. Thirty rats had been separated into five groups. The results showed the highest significant increase in body weight gain, total food intake, and feed efficiency noticed in the aspartame group followed by sucralose, sucrose, and sorbitol, respectively. In contrast to RBCs and platelets, all sweeteners significantly reduced the hemoglobin level, Hct %, and WBC count. The aspartame group showed the highest decline in glycoproteins, steroids, and T3, and T4 hormones and a dramatic elevation in thyroid stimulating hormone, eicosanoid, and amine hormones compared with the control group. A vigorous elevation in anti- and proinflammatory cytokine levels was observed in the aspartame group, followed by sucralose, sucrose, and sorbitol groups. Aspartame has the highest docking scores when studying the interactions of sweeteners and a target protein associated with hormones or cytokines using in silico molecular docking, with the best absorption, distribution, metabolism, elimination, and toxicity properties compared to the remaining sweeteners.

Glycolipid Metabolic Disorders, Metainflammation, Oxidative Stress, and Cardiovascular Diseases: Unraveling Pathways

Glycolipid metabolic disorders (GLMDs) are various metabolic disorders resulting from dysregulation in glycolipid levels, consequently leading to an increased risk of obesity, diabetes, liver dysfunction, neuromuscular complications, and cardiorenal vascular diseases (CRVDs). In patients with GLMDs, excess caloric intake and a lack of physical activity may contribute to oxidative stress (OxS) and systemic inflammation. This study aimed to review the connection between GLMD, OxS, metainflammation, and the onset of CRVD. GLMD is due to various metabolic disorders causing dysfunction in the synthesis, breakdown, and absorption of glucose and lipids in the body, resulting in excessive ectopic accumulation of these molecules. This is mainly due to neuroendocrine dysregulation, insulin resistance, OxS, and metainflammation. In GLMD, many inflammatory markers and defense cells play a vital role in related tissues and organs, such as blood vessels, pancreatic islets, the liver, muscle, the kidneys, and adipocytes, promoting inflammatory lesions that affect various interconnected organs through their signaling pathways. Advanced glycation end products, ATP-binding cassette transporter 1, Glucagon-like peptide-1, Toll-like receptor-4, and sphingosine-1-phosphate (S1P) play a crucial role in GLMD since they are related to glucolipid metabolism. The consequences of this is system organ damage and increased morbidity and mortality.

Effect of stevia on blood glucose and HbA1C: A meta-analysis

BACKGROUND

The study investigates substituting non-nutritive sweeteners (NNS) for sugar to address health concerns related to excess sugar intake. It specifically examines how stevia affects insulin and blood glucose levels. The systematic review and meta-analysis aim to evaluate stevia's impact on glycemic indices.

METHODS

We conducted a systematic review and meta-analysis following PRISMA guidelines, including 26 studies with 1439 participants. The PROSPERO registration number for this research is CRD42023414411. We systematically searched PubMed (MEDLINE), Scopus, Web of Science, and Google Scholar. Additionally, we thoroughly reviewed the reference lists of the articles we extracted and relevant reviews. Two evaluators independently carried out screening, quality assessment, and data extraction. The GRADE (grading of recommendations, assessment, development, and evaluation) approach was utilized to evaluate the certainty of the evidence.

RESULTS

Stevia consumption was associated with significantly reducing blood glucose levels (WMD: -3.84; 95 % CI: -7.15, -0.53; P = 0.02, low certainty), especially in individuals with higher BMI, diabetes, and hypertension. Dose-response analysis revealed a decrease in blood glucose for ≥3342 mg/day of stevia consumption. Stevia consumption has been shown to reduce blood glucose levels within 1-4 months, as evidenced by dose-response analysis (less than 120 days) and subgroup analysis (more than four weeks). However, stevia did not significantly affect insulin concentration or HbA1C levels (very low and low certainty, respectively).

CONCLUSIONS

Low certainty evidence showed that stevia improved blood glucose control, especially when consumed for less than 120 days. However, more randomized trials with higher stevia dosages are required.

Does sweetness exposure drive 'sweet tooth'?

It is widely believed that exposure to sweetened foods and beverages stimulates the liking and desire for sweetness. Here we provide an updated review of the empirical evidence from human research examining whether exposure to sweet foods or beverages influences subsequent general liking for sweetness (‘sweet tooth’), based on the conclusions of existing systematic reviews and more recent research identified from a structured search of literature. Prior reviews have concluded that the evidence for a relationship between sweet taste exposure and measures of sweet taste liking is equivocal, and more recent primary research generally does not support the view that exposure drives increased liking for sweetness, in adults or children. In intervention trials using a range of designs, acute exposure to sweetness usually has the opposite effect (reducing subsequent liking and desire for sweet taste), while sustained exposures have no significant effects or inconsistent effects. Recent longitudinal observational studies in infants and children also report no significant associations between exposures to sweet foods and beverages with measures of sweet taste preferences. Overall, while it is widely assumed that exposure to sweetness stimulates a greater liking and desire for sweetness, this is not borne out by the balance of empirical evidence. While new research may provide a more robust evidence base, there are also a number of methodological, biological and behavioural considerations that may underpin the apparent absence of a positive relationship between sweetness exposure and liking.

Acute and two-week effects of neotame, stevia rebaudioside M and sucrose-sweetened biscuits on postprandial appetite and endocrine response in adults with overweight/obesity-a randomised crossover trial from the SWEET consortium

BACKGROUND

Sweeteners and sweetness enhancers (S&SE) are used to replace energy yielding sugars and maintain sweet taste in a wide range of products, but controversy exists about their effects on appetite and endocrine responses in reduced or no added sugar solid foods. The aim of the current study was to evaluate the acute (1 day) and repeated (two-week daily) ingestive effects of 2 S&SE vs. sucrose formulations of biscuit with fruit filling on appetite and endocrine responses in adults with overweight and obesity.

METHODS

In a randomised crossover trial, 53 healthy adults (33 female, 20 male) with overweight/obesity in England and France consumed biscuits with fruit filling containing 1) sucrose, or reformulated with either 2) Stevia Rebaudioside M (StRebM) or 3) Neotame daily during three, two-week intervention periods with a two-week washout. The primary outcome was composite appetite score defined as [desire to eat + hunger + (100 - fullness) + prospective consumption]/4.

FINDINGS

Each formulation elicited a similar reduction in appetite sensations (3-h postprandial net iAUC). Postprandial insulin (2-h iAUC) was lower after Neotame (95% CI (0.093, 0.166); p < 0.001; d = -0.71) and StRebM (95% CI (0.133, 0.205); p < 0.001; d = -1.01) compared to sucrose, and glucose was lower after StRebM (95% CI (0.023, 0.171); p < 0.05; d = -0.39) but not after Neotame (95% CI (-0.007, 0.145); p = 0.074; d = -0.25) compared to sucrose. There were no differences between S&SE or sucrose formulations on ghrelin, glucagon-like peptide 1 or pancreatic polypeptide iAUCs. No clinically meaningful differences between acute vs. two-weeks of daily consumption were found.

INTERPRETATION

In conclusion, biscuits reformulated to replace sugar using StRebM or Neotame showed no differences in appetite or endocrine responses, acutely or after a two-week exposure, but can reduce postprandial insulin and glucose response in adults with overweight or obesity.

FUNDING

The present study was funded by the Horizon 2020 program: Sweeteners and sweetness enhancers: Impact on health, obesity, safety and sustainability (acronym: SWEET, grant no: 774293).

Designing healthier and more sustainable ultraprocessed foods

The food industry has been extremely successful in creating a broad range of delicious, affordable, convenient, and safe food and beverage products. However, many of these products are considered to be ultraprocessed foods (UPFs) that contain ingredients and are processed in a manner that may cause adverse health effects. This review article introduces the concept of UPFs and briefly discusses food products that fall into this category, including beverages, baked goods, snacks, confectionary, prepared meals, dressings, sauces, spreads, and processed meat and meat analogs. It then discusses correlations between consumption levels of UPFs and diet-related chronic diseases, such as obesity and diabetes. The different reasons for the proposed ability of UPFs to increase the risk of these chronic diseases are then critically assessed, including displacement of whole foods, high energy densities, missing phytochemicals, contamination with packaging chemicals, hyperpalatability, harmful additives, rapid ingestion and digestion, and toxic reaction products. Then, potential strategies to overcome the current problems with UPFs are presented, including reducing energy density, balancing nutritional profile, fortification, increasing satiety response, modulating mastication and digestion, reengineering food structure, and precision processing. The central argument is that it may be possible to reformulate and reengineer many UPFs to improve their healthiness and sustainability, although this still needs to be proved using rigorous scientific studies.

Metabolic Effects of Selected Conventional and Alternative Sweeteners: A Narrative Review

Sugar consumption is known to be associated with a whole range of adverse health effects, including overweight status and type II diabetes mellitus. In 2015, the World Health Organization issued a guideline recommending the reduction of sugar intake. In this context, alternative sweeteners have gained interest as sugar substitutes to achieve this goal without loss of the sweet taste. This review aims to provide an overview of the scientific literature and establish a reference tool for selected conventional sweeteners (sucrose, glucose, and fructose) and alternative sweeteners (sucralose, xylitol, erythritol, and D-allulose), specifically focusing on their important metabolic effects. The results show that alternative sweeteners constitute a diverse group, and each substance exhibits one or more metabolic effects. Therefore, no sweetener can be considered to be inert. Additionally, xylitol, erythritol, and D-allulose seem promising as alternative sweeteners due to favorable metabolic outcomes. These alternative sweeteners replicate the benefits of sugars (e.g., sweetness and gastrointestinal hormone release) while circumventing the detrimental effects of these substances on human health.

Acute Intake of Fructose Increases Arterial Pressure in Humans: A Meta-Analysis and Systematic Review

Hypertension is a major cardiac risk factor. Higher blood pressures are becoming more prevalent due to changing dietary habits. Here, we evaluated the impact on blood pressure in human subjects after acutely ingesting fructose using meta-analysis. A total of 89 studies were collected from four different electronic databases from 1 January 2008 to 1 August 2023. Of these studies, 10 were selected that fulfilled all the criteria for this meta-analysis. Heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), and blood glucose level were analyzed using the Cohen's d analysis or standardized mean difference at a confidence interval (CI) of 95%. The SBP, DBP, and MAP showed medium effect size; HR and glucose level displayed small effect size. The standardized mean difference of normal diet groups and fructose diet groups showed a significant increase in SBP (p = 0.04, REM = 2.30), and DBP (p = 0.03, REM = 1.48) with heterogeneity of 57% and 62%, respectively. Acute fructose ingestion contributes to an increase in arterial pressure in humans. The different parameters of arterial pressure in humans correlated with each other. These findings support further rigorous investigation, retrospective of necessity, into the effect of chronic dietary of fructose in humans in order to better understand the impact on long term arterial pressure.

Patterns and Predictors of Low-Calorie Sweetener Consumption during Pregnancy: Findings from a National Survey

Recently, the World Health Organization recommended avoiding low-calorie sweeteners (LCS) during pregnancy due to concerns that it may be linked to adverse pregnancy outcomes and offspring wellbeing. This study examined the patterns and predictors of LCS consumption among pregnant women in Australia. A survey was conducted among 422 pregnant women aged 18-50 years. Sociodemographic, lifestyle, dietary intake including LCS consumption, pregnancy-related characteristics, and awareness about the health effects of LCS were assessed. We used latent class analysis and multinomial logistic regression to identify LCS consumption patterns and predictors of consumption patterns, respectively. The mean (SD) age of the women was 30 (4.6) years. Three LCS consumption patterns were identified: infrequent or non-consumers representing 50% of the women, moderate consumers encompassing 40% of the women, and the remaining were habitual consumers. Over two-thirds (71%) of women were not aware of the potential adverse effects of LCS, and only a quarter of them were concerned about the possible adverse effects on their health and their offspring. Increasing age and living with a medical condition decreased the likelihood of moderate consumption by 7% and 55%, respectively. Frequent sugar-sweetened beverage consumption and gestational diabetes predicted habitual LCS consumption. This research suggested widespread LCS consumption among pregnant women in Australia, but lower awareness of its potential adverse health effects. Interventions to increase awareness of potential adverse effects are warranted.

Acute Intake of Sucrose but Not of the Intense Sweetener Sucralose Is Associated with Post-Prandial Endotoxemia in Healthy Young Adults-A Randomized Controlled Trial

Sugar-rich diets, but also the use of intense sweeteners, may alter intestinal barrier function. Here, we assessed the effect of sucrose and sucralose on post-prandial endotoxemia in a randomized placebo-controlled single-blinded crossover-designed study. Following a 2-day standardization of their diet, healthy men and women received a beverage containing either sucrose, sucralose (iso-sweet) or an isocaloric combination of sucralose + maltodextrin. Plasma endotoxin levels were measured after consumption of the respective beverages. Moreover, the effect of sucrose and sucralose on intestinal permeability was assessed in Caco-2 cells and ex vivo in an everted gut sac model. The nutritional standardization recommended by nutrition societies was associated with a significant decrease in plasma endotoxin levels. The intake of the sucrose-sweetened beverage resulted in a significant increase in plasma endotoxin levels while being unchanged after the intake of sucralose-sweetened beverages. In Caco-2 cells, the challenge with sucrose but not with sucralose significantly increased the permeation of the bacterial endotoxin across the cell monolayer. Xylose permeation in small intestinal everted tissue sacs was significantly higher upon the challenge with sucrose while remaining unchanged in sucralose-challenged sacs. Our data suggest that an acute intake of physiologically relevant amounts of sucrose but not of sucralose can result in post-prandial endotoxemia.

Effect of Non- and Low-Caloric Sweeteners on Substrate Oxidation, Energy Expenditure, and Catecholamines in Humans-A Systematic Review

The use of non- and low-caloric sweetener(s) (NCS and LCS) as a means to prevent overweight and obesity is highly debated, as both NCS and LCS have been proposed to have a negative impact on energy homeostasis. This systematic review aimed to assess the impact of NCS and LCS on fasting and postprandial substrate oxidation, energy expenditure, and catecholamines, compared to caloric sweeteners or water, across different doses and types of NCS and LCS, acutely and in the longer-term. A total of 20 studies were eligible: 16 studies for substrate oxidation and energy expenditure and four studies for catecholamines. Most studies compared the acute effects of NCS or LCS with caloric sweeteners under non-isoenergetic conditions. These studies generally found higher fat oxidation and lower carbohydrate oxidation with NCS or LCS than with caloric sweeteners. Findings for energy expenditure were inconsistent. With the limited number of studies, no convincing pattern for the remaining outcomes and comparisons could be seen. In conclusion, drinks or meals with NCS or LCS resulted in higher fat and lower carbohydrate oxidation compared to caloric sweeteners. No other conclusions could be drawn due to insufficient or inconsistent results. Further studies in this research field are warranted.

Low-Grade Inflammation and Ultra-Processed Foods Consumption: A Review

Low-grade inflammation alters the homeostasis of the organism and favors the onset of many chronic diseases. The global growth in the prevalence of noncommunicable diseases in recent years has been accompanied by an increase in the consumption of ultra-processed foods (UPF). Known to be hyperpalatable, economic and ready-to-eat, increased consumption of UPF has already been recognized as a risk factor for several chronic diseases. Different research groups have tried to investigate whether UPF consumption could promote low-grade inflammation and thus favor the development of noncommunicable diseases. Current evidence highlights the adverse health effects of UPF characteristics, not only due to the nutrients provided by a diet rich in UPF, but also due to the non-nutritive components present in UPF and the effect they may have on gut health. This review aims to summarize the available evidence on the possible relationship between excessive UPF consumption and modulation of low-grade inflammation, as potential promoters of chronic disease.