Targeting Overconsumption of Sugar-Sweetened Beverages vs. Overall Poor Diet Quality for Cardiometabolic Diseases Risk Prevention: Place Your Bets!

Association of healthy beverage index with circadian rhythm and quality of sleep among overweight and obese women: a cross-sectional study

PURPOSE

Circadian rhythm is a behavioral, physiological, and molecular change with a cycle length of approximately 24 h. Changes to the circadian rhythm can result in sleep difficulty. The healthy beverage index (HBI) is a holistic concept for evaluating the quality of overall beverage intake and its association with health-related outcomes in nutritional epidemiological studies. This study aimed to assess the relationship of HBI with circadian rhythm and sleep quality among overweight/obese women.

METHODS

The current study was conducted among 208 overweight and obese women between 18-48 years in Tehran, Iran. We evaluated potential HBI with a valid food frequency questionnaire. Following standard procedures, trained personnel assessed anthropometric measures, blood samples, and other baseline characteristics. The Pittsburgh Sleep Quality Index and the morning-eveningness questionnaire were applied to evaluate sleep quality and circadian rhythm respectively.

RESULTS

The mean (SD) BMI for this study was 30.8 (4.2) kg/m². We observed that subjects in the least tertile had significantly high levels of triglyceride (p = 0.04) and low-density lipoprotein (p = 0.009). High-density lipoprotein was significantly different across the tertiles (p = 0.003). After adjusting for potential covariates, subjects in the second tertile of HBI had 5.07 odds of having the worst quality of sleep as compared to those in the third tertile, p < 0.05. We also observed a significant inverse association between the HBI and the "moderately evening type" participants (OR 0.86; 95% CI 0.68-0.99; p: 0.02) after adjusting for potential confounders.

CONCLUSION

Healthy beverage consumption may have the potential of improving sleep quality among overweight and obese subjects.

LEVEL OF EVIDENCE

Level IV, evidence obtained from a descriptive study.

Associations between adherence to the dietary approaches to stop hypertension (DASH) diet and six glucose homeostasis traits in the Microbiome and Insulin Longitudinal Evaluation Study (MILES)

BACKGROUND AND AIMS

The DASH diet conveys protection against type 2 diabetes mellitus (T2D) Via plant-based and non-plant-based recommendations. Research has not identified which glucose homeostasis pathways are improved. We examined associations between adherence to a DASH diet and six glucose homeostasis traits, probing whether associations could be attributed to the plant-based (DASH-P) and/or non-plant based (DASH-NP) components.

METHODS AND RESULTS

We included data from 295 adults without T2D (age 59.3 ± 9.00 years; 63.46% non-Hispanic White and 36.54% African American, self-reported race ancestry) participating in the Microbiome and Insulin Longitudinal Evaluation Study (MILES). An oral glucose tolerance test (OGTT) yielded fasting plasma glucose, insulin, C-peptide, and insulin secretion, sensitivity, and disposition index. Habitual dietary intake was assessed by food frequency questionnaire (FFQ). Associations between DASH components and glucose homeostasis traits were examined, controlling for demographics, body mass index (BMI), physical activity, and energy intake. For significant associations, the models were repeated with scores for DASH-P and DASH-NP as predictors in the same model. DASH and DASH-P scores were inversely associated with fasting plasma glucose (DASH:β = -0.036 ± 0.012,P = 0.005; DASH-P: β = -0.04 ± 0.017,P = 0.002), and positively associated with insulin sensitivity (DASH:β = 0.022 ± 0.012,P = 0.042; DASH-P: = 0.036 ± 0.015,P = 0.014). The DASH score was also associated with disposition index (β = 0.026 ± 0.013,P = 0.038), but this association did not reach significance with DASH-P (β = 0.035 ± 0.018,P = 0.051). No associations were observed with DASH-NP score (all P > 0.05).

CONCLUSIONS

DASH diet is associated with improvement in specific glucose homeostasis traits, likely arising from increased plant-based foods. Such research may help tailor future dietary advice to specific metabolic risk, and to food groups most effective at improving these.

Food Insecurity, Associated Health Behaviors, and Academic Performance Among Urban University Undergraduate Students

OBJECTIVE

To explore associations between food insecurity, health behaviors, and academic performance among undergraduates at a private, urban US university.

METHODS

A cross-sectional web-based survey was conducted among a convenience sample of New York University undergraduates. Multivariable logistic regression estimated associations of food security (using the 6-item US Household Food Security Survey Module) and health behaviors (fruit/vegetable, beverage and alcohol intakes, and sleep), self-rated health, and academic performance.

RESULTS

Of the 257 students who completed the survey, 41% reported food insecurity. Food insecurity was associated with approximately 2-fold higher odds of sugar-sweetened beverage consumption (adjusted odds ratio, 1.97; 95% confidence interval, 1.14-3.41) and fair/poor health (adjusted odds ratio, 2.29; 95% confidence interval, 1.23-4.25).

CONCLUSIONS AND IMPLICATIONS

Increased awareness of food insecurity and associated health behaviors among students has implications for higher education's provision of on-campus food support programs.

The Association between Online Learning and Food Consumption and Lifestyle Behaviors and Quality of Life in Terms of Mental Health of Undergraduate Students during COVID-19 Restrictions

The COVID-19 pandemic caused the abrupt replacement of traditional face-to-face classes into online classes. Several studies showed that online teaching and learning produced adverse mental health for students. However, no research has been conducted so far analyzing the association between the duration of online and food consumption and lifestyle behaviors and quality of life in terms of mental health of undergraduate students. This study aimed to determine the association between the duration of online learning and food consumption behaviors, lifestyles, and quality of life in terms of mental health among Thai undergraduate students during COVID-19 restrictions. A cross-sectional online survey of 464 undergraduate students was conducted at Chulalongkorn University, Bangkok, Thailand, between March and May 2021. The majority of undergraduate students stated that they spent 3–6 h per day on online learning (76.1%) and used their digital devices such as computers, tablets, or smartphones more than 6 h per day (76.9%). In addition, they had 75.4% of skipping breakfast (≥3 times/week) and 63.8% of sleep duration (6–8 h/day). A higher proportion of students who drank tea or coffee with milk and sugar while online learning was observed. The results found that the increased duration of online learning was significantly associated with skipping breakfast and the frequency of sugary beverage consumption. On the other hand, the increased computer, tablet, and smartphone usage for online learning was correlated with lower sleep duration and a poor quality of life in terms of mental health. The findings from this study contribute to a report of the association between online learning and food consumption and lifestyle behaviors and quality of life of undergraduate students, emphasizing the necessity for intervention strategies to promote healthy behaviors.

Dietary Intake of Adult Residents in Luxembourg Taking Part in Two Cross-Sectional Studies-ORISCAV-LUX (2007-2008) and ORISCAV-LUX 2 (2016-2017)

Background: A balanced diet is an important lifestyle component and has been associated with a reduced risk of chronic diseases. Objectives: To assess dietary intake of adult residents in Luxembourg taking part in two population-based cross-sectional studies (ORISCAV-LUX, 2007–2008 and ORISCAV-LUX 2, 2016–2017). Methods: Dietary intake of the study participants (1242 in 2007/08 and 1326 in 2016/17), 25–69 years old, were evaluated using food-frequency questionnaires (134 items in 2007/2008 and 174 items in 2016/2017) according to the French ANSES-CIQUAL food composition database. Both food-group- and nutrient-based analyses were conducted. Results: Dietary patterns in ORISCAV-LUX 2, 2016–2017, were characterized by an increase in the estimated marginal means (EMM) of the intake of energy, total fat, saturated fatty acids, alcohol, and decreased EMM of total carbohydrates, magnesium, and calcium compared to 2007/08. We also observed an increased EMM of the intake of protein-rich food items and ready-to-eat foods/fast foods, together with a decreased intake of grains, dairy products, and vegetables (all p-values <0.05, linear mixed models). The intake of most micronutrients was stable or slightly increased in ORISCAV-LUX 2 vs. ORISCAV-LUX, except for the drop in magnesium and calcium, and generally met recommendations, in particular, EFSA population reference intakes (PRI), except for vitamin D. Conclusions: Though most micronutrient recommendations were met, nutrient consumption in terms of high energy, total fat, and sodium, as well as low carbohydrates, were not aligned with recommendations for balanced eating.

Sin taxes and their effect on consumption, revenue generation and health improvement: a systematic literature review in Latin America

Sin or public health taxes are excise taxes imposed on the consumption of potentially harmful goods for health [sugar-sweetened beverages (SSBs), tobacco, alcohol, among others], aiming to reduce consumption, raise additional revenue and/or improve population health. This paper assesses the extent to which sin taxes (a) can reduce consumption of potentially harmful goods, (b) raise revenue for national health systems and (c) contribute to population health in Latin America. A systematic literature review was conducted on peer-reviewed and grey literature; endpoints included: impact of raising sin taxes on consumption, ability to raise revenue for health and the possibility of population health improvements. Risk of bias for each study was assessed. The synthesis of the literature on sin tax implementation showed improvements in all three endpoints across the study countries. Following the introduction of sin taxes or by simulating their potential impact, nearly all studies explicitly reported that consumption of potentially harmful goods (mainly SSBs and tobacco) declined; revenue was found to have increased in almost all countries, suggesting that there may be additional scope for further tax increase. Simulated improvements in population health have also been shown, by demonstrating a relationship between sin tax increases and reduction in prevalence of diabetes, stroke, heart attacks and associated deaths. However, sin tax effects on health would be better quantified over the long-term. Data quality and availability challenges did place some limitations on sin tax impact assessment. Sin taxes can be effective in reducing consumption of potentially harmful goods, improve population health and generate additional revenue. Promoting further research on this topic should be a priority.

Association between Consumption of Sugar-Sweetened Beverages and Risk of Cardiovascular Disease in Korean Men: Analysis Based on the Korea National Health and Nutrition Examination Survey 2014-2016

Background

This study aimed to evaluate the association between the high risk of cardiovascular disease (CVD) and the consumption of sugar-sweetened beverages (SSBs) in Korean men.

Methods

This cross-sectional study analyzed the data of 3,705 men (age 30–64 years) who participated in the 2014–2016 Korea National Health and Nutrition Examination Survey (KNHANES). SSB intake was defined as the sum of the intakes of carbonated beverages and fruit juices. Participants were categorized into study groups depending on their intake of SSBs: ≤2, 3–4, or ≥5 times per week. High CVD risk was defined as a 10-year risk of more than 10%, based on the Framingham Heart Study 10-year CVD Risk Calculator. The association between high CVD risk and SSB intake was evaluated using a multivariable-adjusted logistic regression model.

Results

Korean men who consumed SSBs 3–4 and ≥5 times a week showed a multivariate-adjusted odds ratio of 1.49 (95% confidence interval [CI], 1.05–2.11) and 1.61 (95% CI, 0.97–2.67) for high CVD risk, respectively, compared with those who consumed SSBs ≤2 times per week. Additionally, the risk of CVD increased with the increase in the intake of SSBs (P-trend=0.01). In subgroup analysis, no association was observed between SSB intake and high CVD risk in the group with regular physical activity (P for interaction=0.01).

Conclusion

In Korean men, except those with regular physical activity, SSB intake ≥3 times a week is associated with a high risk for CVD (10-year CVD risk ≥10%).

Arterial stiffness is not acutely modified by consumption of a caffeinated soft drink sweetened with high-fructose corn syrup in young healthy adults

We tested the hypothesis that ingestion of a caffeinated soft drink sweetened with high‐fructose corn syrup acutely increases arterial stiffness. In a randomized counterbalanced, crossover design, fourteen healthy adults (25 ± 3 years, 6 women) reported to the laboratory for two experimental visits where 500 ml of tap water (H₂O) or 500 ml of Mountain Dew® (a caffeinated soft drink sweetened with high‐fructose corn syrup (HFCS)) were consumed. Arterial stiffness (carotid‐to‐femoral pulse wave velocity (cfPWV)), peripheral and central blood pressures were measured pre‐consumption, 30 min post‐consumption, and 120 min post‐consumption. Prior to each measurement period, beat‐to‐beat hemodynamic measures were collected. Changes in heart rate, blood pressure, and cardiac output from pre‐consumption did not differ between trials at any timepoint (p ≥ 0.06). Moreover, changes in peripheral or central blood pressures from pre‐consumption did not differ between trials (p ≥ 0.84). Likewise, changes in cfPWV from pre‐consumption to 30 min post‐consumption (HFCS: 0.2 ± 0.3 m/s, H₂O: 0.0 ± 0.3 m/s, p = 0.34) and 120 min post‐consumption (HFCS: 0.3 ± 0.4 m/s, H₂O: 0.2 ± 0.3 m/s, p = 0.77) did not differ. Changes in aortic augmentation pressure, augmentation index, augmentation index corrected to a heart rate of 75 bpm, and reflection magnitude did not differ between conditions at 30 min post‐ (p ≥ 0.55) or 120 min post‐ (p ≥ 0.18) consumption. In healthy young adults, ingesting 500 ml of a commercially available caffeinated soft drink sweetened with high‐fructose corn syrup does not acutely change indices of arterial stiffness and wave reflection.

Sugar- and artificially-sweetened beverages and the risks of chronic kidney disease: a systematic review and dose-response meta-analysis

BACKGROUND

Consumption of sugar or artificially-sweetened beverages (SASBs) has been linked to albuminuria, decline in kidney function, and risk of chronic kidney disease (CKD). However, the results are controversial. We therefore aim to evaluate the effects of sugar or artificially-sweetened beverage consumption on CKD risk.

METHODS

Original observational studies reporting relative risks (RRs) with 95% confidence intervals (CIs) for the association between sugar or artificially-sweetened beverage consumption and impaired renal function or CKD risk in adults were identified using a systematic search of PubMed and EMBASE from inception to 20 February, 2019. Random effects model was applied to derive summary RRs and 95% CIs. Linear and non-linear dose-response relationships were estimated using data from sugar or artificially-sweetened beverage consumption categories in each study.

RESULTS

The summary RR of CKD for high versus low sugar-sweetened beverage consumption was 1.30 (95% CI 0.88-1.94) according to six included studies with a total of 25,455 participants, while the pooled RR of CKD for high versus low artificially sweetened beverage consumption was 1.40 (95% CI 0.65-3.02) according to three studies with a total of 19,995 participants. For dose-response analysis, a significant, increased risk of CKD was observed with the sugar or artificially-sweetened beverage consumption above seven servings per week (P < 0.001).

CONCLUSION

Our study found a positive association between consumption of sugar or artificially-sweetened beverage consumption and CKD, though it did not reach statistical significance. However, the dose-response results suggest that more than seven servings per week should be avoided.

The association between dietary pattern and coronary artery disease: A case-control study

Introduction: Dietary patterns are an important factors in the progress of cardiovascular disease. This study aimed to assess the association between dietary patterns and coronary artery disease (CAD).

Methods: A case-control study was carried on 550 participants. Food expenditure was collected using a validated 168-item food-frequency questionnaire. Dietary patterns were extracted by principal component analysis (PCA). Multiple logistic regressions was used to assess the association between dietary patterns and the risk of CAD.

Results: Three major dietary patterns were identified: the "Quasi-Western Pattern" was characterized by higher intakes of sweets and desserts, snacks, legumes, honey or jam, ketchup, mayonnaise, yellow vegetables, potatoes, red meat, refined grains; the "Sugar and Fast foods Pattern" was characterized by higher intakes of sugar, soft drinks, fast foods, high-fat dairy, hydrogenated fats, and the "Quasi-Mediterranean Pattern" was characterized by higher intakes of fruits, cruciferous vegetables, green leafy vegetables, other vegetables, nuts, coffee. In both sexes, the "Quasi-Western Pattern" and the "Sugar and Fast foods Pattern" were positively associated with the risk of CAD. For "Quasi-Western Pattern", adjusted-ORs were (OR: 1.35, 95% CI: 0.99-1.83, P = 0.05) and (OR: 1.38, 95% CI: 1.03-1.83, P = 0.03)for men and women respectively. The ORs were for "Sugar and Fast foods Pattern" (OR: 3.64, 95% CI:2.25-5.89, P < 0.001) and (OR: 3.91, 95% CI: 2.42-6.63, P < 0.001) for men and women respectively.There was a significant inverse relationship among "Quasi-Mediterranean pattern" and CAD in the crude model in women (OR: 0.7, 95% CI: 0.55-0.89, P = 0.0.004).

Conclusion: High adherence to the "Quasi-Western Pattern" and "Sugar-Fast foods Pattern" dietary patterns were associated with a higher risk of CAD. The "Quasi-Mediterranean pattern" reduced the risk of CAD.

Barriers and Facilitators to Healthy Eating among Adult Food Bank Users

Healthy eating relates to improved health, yet adult food bank users report difficulty accessing healthy foods. Registered nurses can promote healthy eating for food bank recipients by understanding perceived obstacles and facilitators. Urban food bank users completed a survey, and qualitative content analysis was used to analyze four open-ended questions regarding perceptions of healthy eating. In total, 196 adults were included in analysis. Two main categories were identified as perceived facilitators and barriers to healthy eating. Themes from the facilitator category included internal resources and external resources. Themes from the barrier category were personal challenges and environmental issues. Healthy eating is a complex behavior that requires personal motivation, skills, and social/environmental supports to be successfully executed among food bank recipients. Nurses should advocate to leverage food bank resources for healthier eating by offering nurtition counseling at events, optimizing access to fresh fruits and vegetables, and decreasing unhealthy food options.

Sugar-sweetened beverages increases the risk of hypertension among children and adolescence: a systematic review and dose-response meta-analysis

BACKGROUND

In the current systematic review and meta-analysis, we summarized the studies that evaluated the effects of sugar-sweetened beverages (SSBs) intake on blood pressure among children and adolescents.

METHODS

In a systematic search from PubMed, Scopus, Embase and Cochrane electronic databases up to 20 April 2020, the observational studies that evaluated the association between sugar-sweetened beverages intake and hypertension, systolic or diastolic blood pressure (SBP, DBP) were retrieved.

RESULTS

A total of 14 studies with 93873 participants were included in the current meta-analysis. High SSB consumption was associated with 1.67 mmHg increase in SBP in children and adolescents (WMD: 1.67; CI 1.021-2.321; P < 0.001). The difference in DBP was not significant (WMD: 0.313; CI -0.131- 0.757; P = 0.108). High SSB consumers were 1.36 times more likely to develop hypertension compared with low SSB consumers (OR: 1.365; CI 1.145-1.626; P = 0.001). In dose-response meta-analysis, no departure from linearity was observed between SSB intake and change in SBP (P-nonlinearity = 0.707) or DBP (P-nonlinearity = 0.180).

CONCLUSIONS

According to our finding, high SSB consumption increases SBP and hypertension in children and adolescents.

The Impact of Sugar-Sweetened Beverage Consumption on the Liver: A Proteomics-based Analysis

Cardiometabolic complications such as the metabolic syndrome and Type 2 Diabetes Mellitus (T2DM) are major causes of global morbidity and mortality. As sugar-sweetened beverages (SSBs) are implicated in this process, this study aimed to obtain greater mechanistic insights. Male Wistar rats (~200 g) were gavaged with a local SSB every day for a period of six months while the control group was gavaged with an iso-volumetric amount of water. Experimental dosages were calculated according to the surface area-to-volume ratio and were equivalent to 125 mL/day (in human terms). A proteomic analysis was performed on isolated liver samples and thereafter, markers of endoplasmic reticulum (ER) stress, antioxidant/oxidant capacity, calcium regulation, and mitochondrial functionality were assessed. These data show that SSB consumption resulted in (a) the induction of mild hepatic ER stress; (b) altered hepatic mitochondrial dynamics; and (c) perturbed calcium handling across mitochondria-associated ER membranes. Despite significant changes in markers of ER stress, the antioxidant response and calcium handling (proteomics data), the liver is able to initiate adaptive responses to counteract such stressors. However, the mitochondrial data showed increased fission and decreased fusion that may put the organism at risk for developing insulin resistance and T2DM in the longer term.

Artificial sweeteners impair endothelial vascular reactivity: Preliminary results in rodents

BACKGROUND AND AIMS

Prospective epidemiological studies highlighted recently the link between artificial sweeteners (AS) consumption and the risk of developing cardiometabolic diseases. However, underlying mechanisms remain unknown. Thus, the aim of this preliminary study was to characterize, in a healthy rat population, the effect of chronic AS consumption on body composition and vascular function, an early marker for cardiovascular disease.

METHODS AND RESULTS

Healthy Wistar rats followed a 10-week standard diet including the consumption of water sweetened or not with a sucralose/acesulfame potassium solution at different concentrations: for moderate consumption at 1 and 2 mg.kg^-1.day^-1, respectively or high intake at 15 and 15 mg.kg^-1.day^-1 for both molecules (acceptable daily intake). Body fat composition has been evaluated and ex vivo aortic vasomotor function has been investigated with a pharmacological approach.

CONCLUSION

Both groups of AS-treated rats showed a significant increase in subcutaneous and perirenal adipose tissue mass storage, without changes in total body mass. However, rats that have consumed AS at Acceptable Daily Intake (ADI) concentration revealed a significant vascular endothelial dysfunction compared to other groups. These results are interesting because they will help to better explain the observed increase in cardiometabolic risk.

High consumption of energy-dense nutrient-poor foods among low-income groups in the Mississippi Delta and Alabama

OBJECTIVE

To assess the consumption of sugar-sweetened beverages (SSB) and other energy-dense nutrient-poor (EDNP) foods in two Southern low-income communities targeted by the Balance Calories Initiative, a campaign by the top-three American beverage companies intended to reduce the consumption of sugary beverages by 20 % over 10 years.

DESIGN

We conducted self-administered intercept surveys in front of food retail outlets between August and November 2016. We recruited adults with children <18 years living at home and adolescents aged 10-17 years with parental consent.

SETTING

Retail food outlets in Mississippi and Alabama, USA.

PARTICIPANTS

Adults (n 11 311) and adolescents (n 3460).

RESULTS

The percentage of high SSB consumers (≥4 servings/d) was 40·9 % among adult males, 32·3 % among adult females, 43·0 % among adolescent males and 34·4 % among adolescent females (male - female difference, P < 0·0001). In aggregate, respondents also reported consuming a mean of 3 servings of salty snacks, cookies and/or candy in the past 24 h, with adolescent males reporting 4 servings.

CONCLUSIONS

SSB should be a primary target of future interventions to improve dietary intake, but EDNP foods likely contribute as many daily kilojoules as SSB among this population. Future campaigns should aim to limit the consumption of all EDNP foods.

Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial

INTRODUCTION

Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages, but warnings' effects on actual purchase behavior remain uncertain. This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases.

STUDY DESIGN

Participants completed one study visit to a life-sized replica of a convenience store in North Carolina. Participants chose six items (two beverages, two foods, and two household products). One item was randomly selected for them to purchase and take home. Participants also completed a questionnaire. Researchers collected data in 2018 and conducted analyses in 2019.

SETTING/PARTICIPANTS

Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers (usual consumption ≥12 ounces/week).

INTERVENTION

Research staff randomly assigned participants to a health warning arm (sugar-sweetened beverages in the store displayed a front-of-package health warning) or a control arm (sugar-sweetened beverages displayed a control label).

MAIN OUTCOME MEASURES

The primary trial outcome was sugar-sweetened beverage calories purchased. Secondary outcomes included reactions to trial labels (e.g., negative emotions) and sugar-sweetened beverage perceptions and attitudes (e.g., healthfulness).

RESULTS

All 400 participants completed the trial and were included in analyses. Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants. In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity, health warnings led to lower sugar-sweetened beverage purchases (adjusted difference, -31.4 calories; 95% CI= -57.9, -5.0). Unadjusted analyses yielded similar results (difference, -32.9 calories; 95% CI= -58.9, -7.0). Compared with the control label, sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention, negative emotions, thinking about the harms of sugar-sweetened beverage consumption, and anticipated social interactions. Trial arms did not differ on perceptions of sugar-sweetened beverages' added sugar content, healthfulness, appeal/coolness, or disease risk.

CONCLUSIONS

Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT. Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT03511937.

Healthy Weight and Obesity Prevention: JACC Health Promotion Series

Overweight and obesity have reached epidemic levels in the United States and worldwide, and this has contributed to substantial cardiovascular and other health risks. However, controversy exists concerning the causes of obesity and effective modalities for its prevention and treatment. There is also controversy related to the concept of metabolically healthy obesity phenotype, the "obesity paradox," and on the importance of fitness to protect individuals who are overweight or obese from cardiovascular diseases. In this state-of-the-art review, the authors focus on "healthy weight" with the emphasis on the pathophysiologic effects of weight gain on the cardiovascular system; mechanistic/triggering factors; and the role of preventive actions through personal, education/environment, and societal/authoritative factors, as well as factors to provide guidance for caregivers of health promotion. Additionally, the authors briefly review metabolically healthy obesity, the obesity paradox, and issues beyond lifestyle consideration for weight loss with medications and bariatric surgery.

Pediatric-Adapted Liking Survey (PALS): A Diet and Activity Screener in Pediatric Care

Clinical settings need rapid yet useful methods to screen for diet and activity behaviors for brief interventions and to guide obesity prevention efforts. In an urban pediatric emergency department, these behaviors were screened in children and parents with the 33-item Pediatric-Adapted Liking Survey (PALS) to assess the reliability and validity of a Healthy Behavior Index (HBI) generated from the PALS responses. The PALS was completed by 925 children (average age = 11 ± 4 years, 55% publicly insured, 37% overweight/obese by Body Mass Index Percentile, BMI-P) and 925 parents. Child–parent dyads differed most in liking of vegetables, sweets, sweet drinks, and screen time. Across the sample, child and parent HBIs were variable, normally distributed with adequate internal reliability and construct validity, revealing two dimensions (less healthy—sweet drinks, sweets, sedentary behaviors; healthy—vegetables, fruits, proteins). The HBI showed criterion validity, detecting healthier indexes in parents vs. children, females vs. males, privately- vs. publicly-health insured, and residence in higher- vs. lower-income communities. Parent’s HBI explained some variability in child BMI percentile. Greater liking of sweets/carbohydrates partially mediated the association between low family income and higher BMI percentile. These findings support the utility of PALS as a dietary behavior and activity screener for children and their parents in a clinical setting.

Prospective association between added sugars and frailty in older adults

Background

Sugar-sweetened beverages and added sugars (monosaccharides and disaccharides) in the diet are associated with obesity, diabetes, and cardiovascular disease, which are all risk factors for decline in physical function among older adults.

Objective

The aim of this study was to examine the association between added sugars in the diet and incidence of frailty in older people.

Design

Data were taken from 1973 Spanish adults ≥60 y old from the Seniors-ENRICA cohort. In 2008-2010 (baseline), consumption of added sugars (including those in fruit juices) was obtained using a validated diet history. Study participants were followed up until 2012-2013 to assess frailty based on Fried's criteria. Statistical analyses were performed with logistic regression adjusted for age, sex, education, smoking status, body mass index, energy intake, self-reported comorbidities, Mediterranean Diet Adherence Score (excluding sweetened drinks and pastries), TV watching time, and leisure-time physical activity.

Results

Compared with participants consuming <15 g/d added sugars (lowest tertile), those consuming ≥36 g/d (highest tertile) were more likely to develop frailty (OR: 2.27; 95% CI: 1.34, 3.90; P-trend = 0.003). The frailty components "low physical activity" and "unintentional weight loss" increased dose dependently with added sugars. Association with frailty was strongest for sugars added during food production. Intake of sugars naturally appearing in foods was not associated with frailty.

Conclusions

The consumption of added sugars in the diet of older people was associated with frailty, mainly when present in processed foods. The frailty components that were most closely associated with added sugars were low level of physical activity and unintentional weight loss. Future research should determine whether there is a causal relation between added sugars and frailty.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Associations of health-behavior patterns, mental health and self-rated health

Diet quality, physical activity, alcohol use, smoking, sleep and sitting-time are behaviors known to influence health. The aims of this study were to identify how these behaviors co-occur to form distinct health-behavior patterns, and to investigate the relationship between these patterns, and mental and self-rated health. Members of the Australian 10,000 Steps project were invited to participate in an online survey in November-December 2011. The participants self-reported demographic and behavioral characteristics (fruit and vegetable intake, fast food, soft drink and alcohol consumption, smoking, physical activity, sitting-time and sleep), frequency of mental distress and self-rated health. Latent Class Analysis was used to identify health-behavior patterns. Latent class regression was used to examine relationships between behavior patterns, mental and self-rated health, and socio-demographic and economic factors. Data were analyzed in October 2017. Complete datasets were obtained from 10,638 participants. Four latent classes were identified, characterized by 'Low-Risk Behavior', 'Poor Sleep, Low-Risk Daytime Behavior', 'Sound Sleep, High-Risk Daytime Behavior' and 'High-Risk Behavior'. The latter two classes, both characterized by high-risk daytime behaviors, were associated with poor self-rated health. Participants in classes with high-risk daytime behaviors were more likely to be younger, non-partnered, non-university educated, from lower income households and work longer hours. Classes characterized by poor sleep quality were associated with higher frequency of mental distress. Findings suggest that experiencing poor sleep is partly independent of daytime behaviors, demographic and socioeconomic factors, but has a strong association with mental health.

Sugar-Sweetened Beverage and Water Intake in Relation to Diet Quality in U.S. Children

INTRODUCTION

Sugar-sweetened beverages (SSBs) are a major contributor to children's added sugar consumption. This study examines whether children's SSB and water intakes are associated with diet quality and total energy intake.

METHODS

Using data on children aged 2-18 years from the 2009-2014 National Health and Nutrition Examination Survey, linear regression models were used to analyze SSB and water intake in relation to Healthy Eating Index 2010 (HEI-2010) scores and total energy intake. Generalized linear models were used to analyze SSB and water intake in relation to the HEI-2010 scores. Analyses were conducted including and excluding caloric contributions from SSBs and were conducted in 2016-2017.

RESULTS

SSB intake was inversely associated with the HEI-2010 total scores (9.5-point lower score comparing more than two servings/day with zero servings/day, p-trend<0.0001) and positively associated with total energy intake (394 kcal higher comparing more than two servings/day with zero servings/day, p-trend<0.0001). The associations between SSB and HEI-2010 total scores were similar when SSBs were excluded from HEI-2010 calculations. Water intake was positively associated with HEI-2010 total scores, but not associated with total energy intake. SSB intake was inversely associated with several HEI-2010 component scores, notably vegetables, total fruit, whole fruit, greens and beans, whole grains, dairy, seafood and plant proteins, and empty calories. Water intake was positively associated with most of the same HEI-2010 component scores.

CONCLUSIONS

Children who consume SSBs have poorer diet quality and higher total energy intake than children who do not consume SSBs. Interventions for obesity and chronic disease should focus on replacing SSBs with water and improving other aspects of diet quality that correlate with SSB consumption.

Sugar- and Intense-Sweetened Drinks in Australia: A Systematic Review on Cardiometabolic Risk

Sugar-sweetened beverages (SSBs) are consumed globally, and have been associated with adverse health outcomes, including weight gain, high blood pressure, type 2 diabetes (T2D), and cardiovascular disease (CVD). There is global variation in beverage formulation in terms of glucose and fructose concentration, which may pose unique health risks linked to glycemic control for Australian consumers. However, previous systematic reviews have overlooked Australian-based literature. A systematic review was performed to synthesise evidence for the associations between consumption of SSBs and intense-sweetened beverages with clinical cardiometabolic risk factors in the Australian population. Articles were sourced from Global Health, Health Source: Nursing/Academic Edition, Medline, and Culmative Index to Nursing and Allied Health Literature. To be eligible for review, studies had to report on the consumption of sugar-sweetened (including fruit juice and fruit drinks) and/or intense-sweetened beverages, and at least one clinical cardiometabolic risk factor. Eighteen studies were included in this review. Research has mostly focused on the relationship between SSB consumption and adiposity-related outcomes. No studies have examined indices of glycaemic control (glucose/insulin), and the evidence for the health impact of intense-sweetened drinks is limited. In addition, studies have primarily been of cross-sectional design, and have examined children and adolescents, as opposed to adult populations. In the Australian population, there is modest but consistent evidence that SSB consumption has adverse associations with weight, but there is insufficient data to assess relationships with cardiometabolic outcomes.