Sugar-sweetened beverages and health: where does the evidence stand?

Obesity and Nutrigenetics Testing: New Insights

BACKGROUND

Obesity results from interactions between environmental factors, lifestyle, and genetics. In this scenario, nutritional genomics and nutrigenetic tests stand out, with the promise of helping patients avoid or treat obesity. This narrative review investigates whether nutrigenetic tests may help to prevent or treat obesity. Scientific studies in PubMed Science Direct were reviewed, focusing on using nutrigenetic tests in obesity. The work showed that few studies address the use of tools in obesity. However, most of the studies listed reported their beneficial effects in weight loss. Ethical conflicts were also discussed, as in most countries, there are no regulations to standardize these tools, and there needs to be more scientific knowledge for health professionals who interpret them. International Societies, such as the Academy of Nutrition and Dietetics and the Brazilian Association for the Study of Obesity and Metabolic Syndrome, do not recommend nutrigenetic tests to prevent or treat obesity, especially in isolation. Advancing nutrigenetics depends on strengthening three pillars: regulation between countries, scientific evidence with clinical validity, and professional training.

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.

Sugar Reduction Initiatives in the Eastern Mediterranean Region: A Systematic Review

This systematic review aims to identify and characterize existing national sugar reduction initiatives and strategies in the Eastern Mediterranean Region. For this purpose, a systematic review of published and grey literature was performed. A comprehensive list of search terms in the title/abstract/keyword fields was used to cover the four following concepts (1) sugar, (2) reduction OR intake, (3) policy and (4) EMR countries. A total of 162 peer-reviewed documents were identified, until the 2nd of August 2022. The key characteristics of the identified national strategies/initiatives included the average sugar intake of each country's population; sugar levels in food products/beverages; implementation strategies (taxation; elimination of subsidies; marketing regulation; reformulation; consumer education; labeling; interventions in public institution settings), as well as monitoring and evaluation of program impact. Twenty-one countries (95%) implemented at least one type of sugar reduction initiatives, the most common of which was consumer education (71%). The implemented fiscal policies included sugar subsidies' elimination (fourteen countries; 67%) and taxation (thirteen countries 62%). Thirteen countries (62%) have implemented interventions in public institution settings, compared to twelve and ten countries that implemented food product reformulation and marketing regulation initiatives, respectively. Food labeling was the least implemented sugar reduction initiative (nine countries). Monitoring activities were conducted by four countries only and impact evaluations were identified in only Iran and Kingdom of Saudi Arabia (KSA). Further action is needed to ensure that countries of the region strengthen their regulatory capacities and compliance monitoring of sugar reduction policy actions.

Relation of Change or Substitution of Low- and No-Calorie Sweetened Beverages With Cardiometabolic Outcomes: A Systematic Review and Meta-analysis of Prospective Cohort Studies

BACKGROUND

Adverse associations of low- and no-calorie sweetened beverages (LNCSB) with cardiometabolic outcomes in observational studies may be explained by reverse causality and residual confounding.

PURPOSE

To address these limitations we used change analyses of repeated measures of intake and substitution analyses to synthesize the association of LNCSB with cardiometabolic outcomes.

DATA SOURCES

MEDLINE, Embase, and the Cochrane Library were searched up to 10 June 2021 for prospective cohort studies with ≥1 year of follow-up duration in adults.

STUDY SELECTION

Outcomes included changes in clinical measures of adiposity, risk of overweight/obesity, metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease, and total mortality.

DATA EXTRACTION

Two independent reviewers extracted data, assessed study quality, and assessed certainty of evidence using GRADE. Data were pooled with a random-effects model and expressed as mean difference (MD) or risk ratio (RR) and 95% CI.

DATA SYNTHESIS

A total of 14 cohorts (416,830 participants) met the eligibility criteria. Increase in LNCSB intake was associated with lower weight (5 cohorts, 130,020 participants; MD -0.008 kg/year [95% CI -0.014, -0.002]). Substitution of LNCSB for sugar-sweetened beverages (SSB) was associated with lower weight (three cohorts, 165,579 participants; MD, -0.12 [-0.14, -0.10,] kg/y) and lower incidence of obesity (OB) (one cohort, 15,765 participants; RR 0.88 [95% CI 0.88, 0.89]), coronary heart disease (six cohorts, 233,676 participants; 0.89 [0.81, 0.98]), cardiovascular disease mortality (one cohort, 118,363 participants; 0.95 [0.90, 0.99]), and total mortality (one cohort, 118,363 participants; 0.96 [0.94, 0.98]) with no adverse associations across other outcomes. Substitution of water for SSB showed lower weight (three cohorts, 165,579 participants; MD -0.10 kg/year [-0.13, -0.06]), lower waist circumference (one cohort, 173 participants; -2.71 cm/year [-4.27, -1.15]) and percent body fat (one cohort, 173 participants; -1.51% per year [-2.61, -0.42]), and lower incidence of OB (one cohort, 15,765 participants; RR 0.85 [0.75, 0.97]) and T2D (three cohorts, 281,855 participants; 0.96 [0.94, 0.98]). Substitution of LNCSB for water showed no adverse associations.

LIMITATIONS

The evidence was low to very low certainty owing to downgrades for imprecision, indirectness, and/or inconsistency.

CONCLUSIONS

LNCSB were not associated with cardiometabolic harm in analyses that model the exposure as change or substitutions. The available evidence provides some indication that LNCSB in their intended substitution for SSB may be associated with cardiometabolic benefit, comparable with the standard of care, water.

Dietary Intake and Sources of Added Sugars in Various Food Environments in Costa Rican Adolescents

Consumption of added sugars, especially from sugar-sweetened beverages (SSBs), has been associated with several negative health outcomes during adolescence. This study aimed to identify dietary intake and food sources of added sugars in the home, school, and neighborhood environments of Costa Rican adolescents. Dietary intake of added sugars was determined using 3-day food records in a cross-sectional study of 818 adolescents aged 12 to 19 and enrolled in rural and urban schools in the province of San José. On average, 90% of adolescents consumed more than 10% of their total energy intake from added sugars. Furthermore, 74.0% of added sugars were provided at home, 17.4% at school, and 8.6% in the neighborhood. Added sugars were primarily provided by frescos (29.4%), fruit-flavored still drinks (22.9%), and sugar-sweetened carbonated beverages (12.3%), for a total contribution of 64.6%. Our findings suggest that Costa Rican adolescents have a plethora of added sugar sources in all food environments where they socialize. However, it is relevant for public health to consider the home and school environments as fundamental units of interventions aimed at reducing added sugars in the adolescent diet. Frescos prepared at home and school and fruit-flavored still drinks must be the focus of these interventions.

Longitudinal geo-referenced field evidence for the heightened BMI responsiveness of obese women to price discounts on carbonated soft drinks

There is increasing interest in the effect that food environments may have on obesity, particularly through mechanisms related to the marketing and consumption of calorie-dense, nutrient-poor foods and sugary beverages. Price promotions, such as temporary price discounts, have been particularly effective in the marketing of carbonated soft drinks (CSDs) among consumers. Research has also suggested that the purchasing behavior of consumer groups may be differentially sensitive to price discounts on CSDs, with obese women particularly sensitive. In addition, the intensity of price discount in a person's food environment may also vary across geography and over time. This study examines whether the weight change of obese women, compared to overweight or normal BMI women, is more sensitive to the intensity of price discounts on CSDs in the food environment. This study used longitudinal survey data from 1622 women in the Montreal Neighborhood Networks and Health Aging (MoNNET-HA) Panel. Women were asked to report their height and weight in 2008, 2010 and 2013 in order to calculate women's BMI in 2008 and their change of weight between 2008 and 2013. Women's exposure to an unhealthy food environment was based on the frequency in which their neighborhood food stores placed price discounts on CSDs in 2008. The price discount frequency on CSDs within women's neighborhoods was calculated from Nielsen point-of sales transaction data in 2008 and geocoded to participant's forward sortation area. The prevalence of obesity and overweight among MoNNET-HA female participants was 18.3% in 2008, 19.9% in 2010 and 20.7% in 2013 respectively. Results showed that among obese women, exposure to unhealthy food environments was associated with a 3.25 kilogram (SE = 1.35, p-value = 0.02) weight gain over the five-year study period. Exposure to price discounts on CSDs may disproportionately affect and reinforce weight gain in women who are already obese.

A youth empowerment intervention to prevent childhood obesity: design and methods for a cluster randomized trial of the H2GO! program

BACKGROUND

Reducing sugar-sweetened beverage (SSB) consumption is a promising dietary target for childhood obesity prevention. This paper describes the design and methods of a cluster randomized trial of H2GO!, a youth empowerment intervention to prevent childhood obesity through reducing SSB consumption among a low-income, ethnically diverse sample of youth.

METHODS

This cluster randomized controlled trial is an academic-community partnership with the Massachusetts Alliance of Boys and Girls Clubs (BGC). Ten BGC sites will be randomly assigned to the H2GO! intervention or a wait-list, usual care control. Eligible study participants will be N = 450 parent-child pairs (youth ages 9-12 years and their parents/caregivers) recruited from participating BGCs. The 6-week in-person H2GO! intervention consists of 12 group-based sessions delivered by BGC staff and youth-led activities. An innovative feature of the intervention is the development of youth-produced narratives as a strategy to facilitate youth empowerment and parental engagement. Child outcomes include measured body mass index z scores (zBMI), beverage intake, and youth empowerment. Parent outcomes include beverage intake and availability of SSBs at home. Outcomes will be measured at baseline and at 2, 6, and 12 months. With a 75% retention rate, the study is powered to detect a minimum group difference of 0.1 zBMI units over 12 months.

DISCUSSION

Empowering youth may be a promising intervention approach to prevent childhood obesity through reducing SSB consumption. This intervention was designed to be delivered through BGCs and is hypothesized to be efficacious, relevant, and acceptable for the target population of low-income and ethnically diverse youth.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04265794 . Registered 11 February 2020.

Genetic Variation, Diet, Inflammation, and the Risk for COVID-19

COVID-19, which is caused by SARS-CoV-2, is characterized by various symptoms, ranging from mild fatigue to life-threatening pneumonia, "cytokine storm," and multiorgan failure. The manifestation of COVID-19 may lead to a cytokine storm, i.e., it facilitates viral replication that triggers a strong release of cytokines, which then modulates the immune system and results in hyperinflammation. Today's diet is high in omega-6 fatty acids and deficient in omega-3 fatty acids; this, along with a high fructose intake, leads to obesity, which is a chronic state of low-grade inflammation. Omega-6 fatty acids are proinflammatory and prothrombotic whereas omega-3 fatty acids are less proinflammatory and thrombotic. Furthermore, omega-3 fatty acids make specialized lipid mediators, namely resolvins, protectins, and maresins, that are potent anti-inflammatory agents. Throughout evolution there was a balance between omega-6 and omega-3 fatty acids with a ratio of 1-2/1 omega-6/omega-3, but today this ratio is 16-20/1 omega-6/omega-3, leading to a proinflammatory state. In addition, genetic variants in FADS1, FADS2, ELOV-2, and ELOV-5 lead to a more efficient biosynthesis of long-chain polyunsaturated fatty acids (PUFAs), e.g., of linoleic acid (LA) to arachidonic acid (ARA), and (alpha-linolenic acid) (ALA) to eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), leading to higher ARA levels. Because the US diet is already high in omega-6 fatty acids, the increased biosynthesis of ARA in people with the derived FADS haplotype (haplotype D) leads to an increased production of leukotrienes, thromboxanes, C-reactive protein (CRP), and eventually elevated levels of cytokines, like interleukin (IL)-1, IL-6, and tumor necrosis factor (TNF), which may increase susceptibility to COVID-19. About 80% of African Americans, 50% of Hispanics, and 45% of European Americans have the FADS haplotype D and are thus efficient metabolizers, which could account for the higher vulnerability of these populations to COVID-19. Therefore, another reason that African Americans and Hispanics are more susceptible to COVID-19 is that they have a higher frequency of haplotype D, which is no longer beneficial in today's environment and diet. Genetic variation must be considered in all studies of disease development and therapy because it is important to the practice of precision nutrition by physicians and other health professionals. The objective of this commentary is to emphasize the importance of genetic variation within populations and its interaction with diet in the development of disease. Differences in the frequency of genes and their interactions with nutrients in various population groups must be considered among the factors contributing to health disparities in the development of COVID-19. A balanced omega-6/omega-3 ratio is essential to health. Physicians should measure their patients' fatty acids and recommend decreasing the intake of foods rich in omega-6 fatty acids and increasing the intake of omega-3 fatty acids along with fruits and vegetables.

Distribution of sugar-sweetened beverage sales volume by sugar content in the United States: implications for tiered taxation and tax revenue

This study draws on data on sales volume, brand-level market shares, and sugar content to calculate the distribution of sugar-sweetened beverage (SSB) sales volume by sugar content, propose sugar content thresholds for a tiered tax structure, and estimate tax revenue. The most common SSBs sold had 26 g of sugar/8-oz serving; 70.8% had ≥ 25 g of sugar/8-oz serving, 16.9% were in the 10-15 g range, and 8.7% were in the 16-20 g range. A tiered tax with cut points at < 20 g and < 5 g of sugar/8-oz serving is proposed. A tax of 1¢/oz for SSBs in the second tier and 2¢/oz in third tier is projected to raise $18.2 billion in tax revenue similar to the 1.5¢/oz flat tax projection ($18.0 billion) but would yield 9% lower SSB volume. Understanding the distribution of SSB sales volume by sugar content informs policymakers on tiered tax structures, which may discourage consumption of SSBs with high levels of sugar and incentivize reformulation.

Oakland's sugar-sweetened beverage tax: Impacts on prices, purchases and consumption by adults and children

Several cities in the U.S. have implemented taxes on sugar-sweetened beverages (SSBs) in an attempt to improve public health and raise revenue. On July 1, 2017, Oakland introduced a tax of one cent per ounce on SSBs. In this paper, we estimate the impact of the tax on retail prices, product availability, purchases, and child and adult consumption of taxed beverages in Oakland, as well as of potential substitute beverages. We collected data from Oakland stores and their customers and a matched group of stores in surrounding counties and their customers. We collected information in the months prior to the implementation of the tax and again a year later on: (1) prices, (2) purchase information from customers exiting the stores, and (3) a follow-up household survey of adults and child beverage purchases and consumption. We use a difference-in-differences identification strategy to estimate the impact of the tax on prices, purchases, and consumption of taxed beverages. We find that roughly 60 percent of the tax was passed on to consumers in the form of higher prices. There was a slight decrease in the volume of SSBs purchased per shopping trip in Oakland and a small increase in purchases at stores outside of the city, resulting in a decrease in purchases of 11.33 ounces per shopping trip that is not statistically significant. We find some evidence of increased shopping by Oakland residents at stores outside of the city. We do not find evidence of substantial changes in the overall consumption of SSBs or of added sugars consumed through beverages for either adults or children after the tax.

Cariogenicity induced by commercial carbonated beverages in an experimental biofilm-caries model

Objectives

Frequent consumption of sugars-containing carbonated beverages has been associated with caries, but the consequences on the dental biofilm remain unclear. The aim was to evaluate the effect of commercial carbonated beverages and their sugar-free version on enamel and dentine demineralization and on the cariogenic properties of Streptococcus mutans biofilms.

Materials and Methods

Biofilms of S. mutans UA159 were grown on enamel and dentin slabs and exposed 3 times/day for 5 min, to a commercial cola or orange-flavored carbonated beverage or to their sugar-free version. Biofilms/slabs were recovered to assess biomass, viable microorganisms, protein content and polysaccharides. Demineralization was estimated by the variation of Knoop surface microhardness.

Results

Exposures to the biofilm with sugars-containing carbonated beverages resulted in similar biomass, viable microorganisms, proteins, and polysaccharides than sucrose (P < 0.05). The sugar-free cola and orange-flavored drink showed lower effect on the biofilm, as compared with sucrose or their sugared version (P < 0.05). All of the products tested, included the sugar-free, showed higher demineralization than the negative control (P < 0.05).

Conclusions

Sugars-containing carbonated beverages enhance cariogenic activity of S. mutans biofilms, comparable with sucrose. Sugar-free carbonated beverages also have a high demineralizing potential, without affecting biofilm properties.

The impact of the Philadelphia beverage tax on purchases and consumption by adults and children

Numerous U.S. cities have recently enacted taxes on sweetened beverages. To examine the effects of the beverage tax of 1.5 cents per ounce in Philadelphia, we surveyed adults and children in Philadelphia and nearby comparison communities both before the tax and nearly one year after implementation. We find that the tax reduced purchases in Philadelphia stores and that Philadelphia residents increased purchases of taxed beverages outside of the city. The tax reduced the frequency of adults' soda consumption by 31 percent, but had no detectable impacts on adults' consumption of other beverages. The tax had no detectable impact on children's consumption of soda or all taxed beverages, although children who were frequent consumers prior to the tax reduced their consumption after the tax.

The Economics of Taxes on Sugar-Sweetened Beverages: A Review of the Effects on Prices, Sales, Cross-Border Shopping, and Consumption

During the past decade, dozens of countries, regions, and cities have enacted taxes on sugar-sweetened beverages (SSBs). They have been primarily motivated by a desire to raise prices, reduce sales and consumption, improve population health, and raise revenue. This review outlines the economic rationale for SSB taxes and illustrates their predicted effects. It reviews the research on the effects of these taxes on retail prices, sales, cross-border shopping, consumption, and product availability. The evidence indicates that the amount by which taxes increase retail prices (also called the pass-through of the tax) varies by jurisdiction, ranging from less than 50% to 100% of the tax. Sales tend to decrease significantly in the taxing jurisdiction, although this seems to be partly offset by residents increasingly shopping outside of the taxing jurisdiction (i.e., engaging in cross-border shopping).Overall, taxes lower consumption of the taxed beverages by adults, although not for all types of beverages or all groups of consumers. We conclude with suggestions for improving the design of such taxes and directions for future research.

Reducing sugary drink intake through youth empowerment: results from a pilot-site randomized study

BACKGROUND

Efficacious strategies to reduce sugar-sweetened beverage (SSB) consumption among youth are needed. This pilot study assessed the feasibility and preliminary efficacy of a community-based youth empowerment intervention to reduce SSB consumption and obesity risk among a low-income, ethnically diverse sample of youth.

METHODS

The H2GO! intervention was pilot-tested in an afterschool setting (Boys and Girls Clubs (BGC)) in Massachusetts, USA. One site was randomized to receive the intervention; the other site received standard programming. Youth ages 9-12 years and their parents/caregivers were eligible to participate. A total of N = 110 parent-child pairs (N = 55 parent-child pairs per site) were recruited. The 6-week intervention consisted of group-based weekly sessions delivered by trained BGC staff and youth-led activities that engaged parents. Child outcomes included self-reported SSB and water intake and measured body mass index z scores (zBMI). Parent outcomes included self-reported SSB and water intake, SSB purchasing, and availability of SSBs at home. Outcomes were measured at baseline, 2 months, and 6 months. Generalized linear and logistic regression models were used to estimate intervention effects over time.

RESULTS

The final analytic study sample consisted of 100 child participants (38% Black, 20% Hispanic, 13% White, 12% Multiracial, 11% Asian) and 87 parent participants (78.2% female; 78.2% reporting eligibility for the free-or-reduced price lunch program). 6-month retention rates were ≥ 82%. Intervention attendance rates among intervention child participants (N = 51) averaged 78.1% (SD = 10.3). Over half (56.0%) of child participants were overweight or obese at baseline. Relative to the comparison site, intervention site child participants had decreased SSB intake (β = - 1.64; 95% CI: 2.52, - 0.76), increased water intake (β = 1.31; 95% CI: 0.38, 2.23), and decreased zBMI (- 0.23 units; 95% CI: - 0.31, - 0.14) over 6 months (p < 0.001). Intervention parent participants also reported decreased SSB intake (β = - 1.76; 95% CI: - 2.56, - 0.96) and increased water intake (β = 1.75; 95% CI: 1.11, 2.40) than comparison parent participants at 6 months (p < 0.001).

CONCLUSIONS

Findings demonstrate the potential of a youth empowerment intervention on reducing SSB intake and zBMI among a diverse sample. Findings will guide a larger cluster-randomized controlled trial to test intervention efficacy on preventing childhood obesity, as well as inform future interventions that aim to target additional diet and physical activity behaviors through youth empowerment.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02890056 . Registered 31 August 2016.

Attitudes and perceptions among urban South Africans towards sugar-sweetened beverages and taxation

OBJECTIVE

A tax on sugar-sweetened beverages (SSB) was introduced in South Africa in April 2018. Our objective was to document perceptions and attitudes among urban South Africans living in Soweto on factors that contribute to their SSB intake and on South Africa's use of a tax to reduce SSB consumption.

DESIGN

We conducted six focus group discussions using a semi-structured guide.

SETTING

The study was conducted in Soweto, Johannesburg, South Africa, 3 months before South Africa's SSB tax was implemented.

PARTICIPANTS

Adults aged 18 years or above living in Soweto (n 57).

RESULTS

Participants reported frequent SSB consumption and attributed this to habit, addiction, advertising and wide accessibility of SSB. Most of the participants were not aware of the proposed SSB tax; when made aware of the tax, their responses included both beliefs that it would and would not result in reduced SSB intake. However, participants indicated cynicism with regard to the government's stated motivation in introducing the tax for health rather than revenue reasons.

CONCLUSIONS

While an SSB tax is a policy tool that could be used with other strategies to reduce people's high level of SSB consumption in Soweto, our findings suggest a need to complement the SSB tax with a multipronged behaviour change strategy. This strategy could include both environmental and individual levers to reduce SSB consumption and its associated risks.

Obesity: global epidemiology and pathogenesis

The prevalence of obesity has increased worldwide in the past ~50 years, reaching pandemic levels. Obesity represents a major health challenge because it substantially increases the risk of diseases such as type 2 diabetes mellitus, fatty liver disease, hypertension, myocardial infarction, stroke, dementia, osteoarthritis, obstructive sleep apnoea and several cancers, thereby contributing to a decline in both quality of life and life expectancy. Obesity is also associated with unemployment, social disadvantages and reduced socio-economic productivity, thus increasingly creating an economic burden. Thus far, obesity prevention and treatment strategies - both at the individual and population level - have not been successful in the long term. Lifestyle and behavioural interventions aimed at reducing calorie intake and increasing energy expenditure have limited effectiveness because complex and persistent hormonal, metabolic and neurochemical adaptations defend against weight loss and promote weight regain. Reducing the obesity burden requires approaches that combine individual interventions with changes in the environment and society. Therefore, a better understanding of the remarkable regional differences in obesity prevalence and trends might help to identify societal causes of obesity and provide guidance on which are the most promising intervention strategies.

Understanding beverage taxation: Perspective on the Philadelphia Beverage Tax's novel approach

Despite the growing global trend of sugar-sweetened beverage (SSB) taxes for their potential as an untapped source of revenue and as a public health boon, these legislative efforts remain controversial. Multiple articles have reviewed this trend in recent years from modeling of long-term impacts to short-term empirical studies, yet most comprehensive, long-term health impact assessments remain forthcoming. These multi-faceted efficacy studies combined with case-based assessments of the policy process, descriptive pieces highlighting unique features of the policy and reflective perspectives targeting unanswered questions create a comprehensive body of literature to help inform present and future legislative efforts. The passage of the Philadelphia Beverage tax required a mix of political entrepreneurs, timing and context; while uniquely employing a nonpublic health frame, specific earmarking and a broadened scope with the inclusion of diet beverages. This perspective on the Philadelphia Beverage Tax will describe the passage and novel features of the Philadelphia Beverage Tax with a discussion of the ethical questions unique to this case.

Sugar in Infants, Children and Adolescents: A Position Paper of the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition

The consumption of sugars, particularly sugar-sweetened beverages (SSBs; beverages or drinks that contain added caloric sweeteners (ie, sucrose, high-fructose corn syrup, fruit juice concentrates), in European children and adolescents exceeds current recommendations. This is of concern because there is no nutritional requirement for free sugars, and infants have an innate preference for sweet taste, which may be modified and reinforced by pre- and postnatal exposures. Sugar-containing beverages/free sugars increase the risk for overweight/obesity and dental caries, can result in poor nutrient supply and reduced dietary diversity, and may be associated with increased risk of type 2 diabetes mellitus, cardiovascular risk, and other health effects. The term "free sugars," includes all monosaccharides/disaccharides added to foods/beverages by the manufacturer/cook/consumer, plus sugars naturally present in honey/syrups/unsweetened fruit juices and fruit juice concentrates. Sugar naturally present in intact fruits and lactose in amounts naturally present in human milk or infant formula, cow/goat milk, and unsweetened milk products is not free sugar. Intake of free sugars should be reduced and minimised with a desirable goal of <5% energy intake in children and adolescents aged ≥2 to 18 years. Intake should probably be even lower in infants and toddlers <2 years. Healthy approaches to beverage and dietary consumption should be established in infancy, with the aim of preventing negative health effects in later childhood and adulthood. Sugar should preferably be consumed as part of a main meal and in a natural form as human milk, milk, unsweetened dairy products, and fresh fruits, rather than as SSBs, fruit juices, smoothies, and/or sweetened milk products. Free sugars in liquid form should be replaced by water or unsweetened milk drinks. National Authorities should adopt policies aimed at reducing the intake of free sugars in infants, children and adolescents. This may include education, improved labelling, restriction of advertising, introducing standards for kindergarten and school meals, and fiscal measures, depending on local circumstances.

Predicting Physical Activity and Healthy Nutrition Behaviors Using Social Cognitive Theory: Cross-Sectional Survey among Undergraduate Students in Chongqing, China

(1) Background: Generally suggested public health measures to reduce obesity were to limit television (TV) viewing, enhance daily physical activities, enable the consumption of fruit and vegetables, and reduce sugar-sweetened beverage intake. This study analyzed the extent to which selected social cognitive theory constructs can predict these behaviors among Chinese undergraduate students. (2) Methods: This cross-sectional study included 1976 undergraduate students from six universities in Chongqing, China. A self-administered five-point Likert common physical activity and nutrition behavior scale based on social cognitive theory was utilized. (3) Results: This study included 687 (34.77%) males and 1289 (65.23%) females. A total of 60.14% of the students engaged in exercise for less than 30 min per day. Approximately 16.5% of the participants spent at least 4 h watching TV and sitting in front of a computer daily. Approximately 79% of the participants consumed less than five cups of fruit and vegetables daily. Undergraduate students who had high self-efficacy scores had more leisure time physical activities. Those who have high expectation scores had considerable time watching TV and sitting in front of a computer. Undergraduate students who had high expectation and self-efficacy scores had substantially low consumption of sugar-sweetened beverages. Those who had high self-efficacy scores consumed considerable amounts of fruit and vegetables. Furthermore, the type of university, BMI group, gender, age, lack of siblings, and grade level were associated with the aforementioned four behaviors. (4) Conclusion: Physical inactivity and unhealthy nutrition behaviors are common among undergraduate students. This study used social cognitive theory to provide several implications for limiting the TV viewing, enhancing daily physical activities, consuming fruit and vegetables, and reducing sugar-sweetened beverage intake among undergraduate students.

The school environment and sugar-sweetened beverage consumption among Guatemalan adolescents

OBJECTIVE

The current study sought to examine Guatemalan adolescents' consumption of sugar-sweetened beverages (SSB), identify which individual-level characteristics are associated with SSB consumption and describe school characteristics that may influence students' SSB consumption.

DESIGN

Within this observational pilot study, a questionnaire was used to assess students' consumption of three varieties of SSB (soft drinks, energy drinks, sweetened coffees/teas), as well as a variety of sociodemographic and behavioural characteristics. We collected built environment data to examine aspects of the school food environment. We developed Poisson regression models for each SSB variety and used descriptive analyses to characterize the sample.

SETTING

Guatemala City, Guatemala.

SUBJECTS

Guatemalan adolescents (n 1042) from four (two public, two private) secondary schools.

RESULTS

Built environment data revealed that students from the two public schools lacked access to water fountains/coolers. The SSB industry had a presence in the schools through advertisements, sponsored food kiosks and products available for sale. Common correlates of SSB consumption included school type, sedentary behaviour, frequency of purchasing lunch in the cafeteria, and frequency of purchasing snacks from vending machines in school and off school property.

CONCLUSIONS

Guatemalan adolescents frequently consume SSB, which may be encouraged by aspects of the school environment. Schools represent a viable setting for equitable population health interventions designed to reduce SSB consumption, including increasing access to clean drinking-water, reducing access to SSB, restricting SSB marketing and greater enforcement of existing food policies.

Assessing the State of Knowledge Regarding the Effectiveness of Interventions to Contain Pandemic Influenza Transmission: A Systematic Review and Narrative Synthesis

BACKGROUND

Influenza pandemics occur when a novel influenza strain, to which humans are immunologically naïve, emerges to cause infection and illness on a global scale. Differences in the viral properties of pandemic strains, relative to seasonal ones, can alter the effectiveness of interventions typically implemented to control seasonal influenza burden. As a result, annual control activities may not be sufficient to contain an influenza pandemic.

PURPOSE

This study seeks to inform pandemic policy and planning initiatives by reviewing the effectiveness of previous interventions to reduce pandemic influenza transmission and infection. Results will inform the planning and design of more focused in-depth systematic reviews for specific types of interventions, thus providing the most comprehensive and current understanding of the potential for alternative interventions to mitigate the burden of pandemic influenza.

METHODS

A systematic review and narrative synthesis of existing systematic reviews and meta-analyses examining intervention effectiveness in containing pandemic influenza transmission was conducted using information collected from five databases (PubMed, Medline, Cochrane, Embase, and Cinahl/EBSCO). Two independent reviewers conducted study screening and quality assessment, extracting data related to intervention impact and effectiveness.

RESULTS AND DISCUSSION

Most included reviews were of moderate to high quality. Although the degree of statistical heterogeneity precluded meta-analysis, the present systematic review examines the wide variety of interventions that can impact influenza transmission in different ways. While it appears that pandemic influenza vaccination provides significant protection against infection, there was insufficient evidence to conclude that antiviral prophylaxis, seasonal influenza cross-protection, or a range of non-pharmaceutical strategies would provide appreciable protection when implemented in isolation. It is likely that an optimal intervention strategy will employ a combination of interventions in a layered approach, though more research is needed to substantiate this proposition.

TRIAL REGISTRATION

PROSPERO 42016039803.

Design and methods for a community-based intervention to reduce sugar-sweetened beverage consumption among youth: H2GO! study

Background

Reducing sugar-sweetened beverage (SSB) intake is an important dietary target among underserved children at high risk for obesity and associated morbidities. Community-based approaches to reduce SSB intake are needed. The use of narrative-based approaches (presenting messages within the context of a story) can facilitate connection with target health messages and empower children as behavior change agents within their families. The H₂GO! program is a community-based behavioral intervention that integrates narrative-based strategies to reduce SSB consumption and promote water intake among school-age youth and parents.

Methods

Guided by the Social Cognitive Theory and the Social Ecological Model, the H₂GO! intervention consists of 6 weekly sessions that target beverage knowledge, attitudes, and behaviors through youth-produced messages and narratives to reduce SSB intake and encourage water intake and parent–child activities. To reach underserved youth and families, we identified Boys & Girls Clubs (B&GC) (youth-based community centers that serve an ethnically diverse and predominantly low socioeconomic status population) as a community partner and study setting. Participants (children ages 9–12 years and their parents) will be recruited from B&GC sites in Massachusetts, USA. Intervention efficacy will be assessed through a site-randomized trial (N = 2 youth-based community sites, pair-matched for size and racial/ethnic composition) with 54 parent–child pairs (N = 108) enrolled per site (N = 216 total). The comparison site will carry on with usual practice. Child and parental SSB and water consumption (primary outcomes) and parent and child beverage knowledge and attitudes (secondary outcomes) will be measured via self-report surveys. Additional outcomes include children’s anthropometric data, additional dietary behaviors, and physical activity. Measures will be collected at baseline, 2 and 6 months follow-up. With an estimated 20 % dropout rate, the study will have 80 % power to detect a group difference of 3.9 servings of SSBs per week.

Discussion

Community-based approaches hold potential for decreasing SSB consumption among youth and families, particularly among underserved populations who are at greater obesity risk. This article describes the design and methods of a community-based behavioral intervention designed to reduce SSB consumption among youth and parents/caregivers.

Trial registration

ClinicalTrials.gov NCT02890056. Date of Registration: August 31, 2016

Consumption of sugar-sweetened beverages and energy drinks and adherence to physical activity and screen time recommendations among adolescents

BACKGROUND

It is recommended that youth aged 12-17 years achieve ≥60 min/day of moderate-to-vigorous physical activity (PA) and limit their recreational screen time (ST) to ≤2 h/day. However, whether unhealthy eating behavior is associated with adherence to PA and ST recommendations in youth is largely unknown.

OBJECTIVE

This study examined the associations between adherence to PA and ST recommendations with consumption of sugar-sweetened beverages (SSBs) and energy drinks (EDs) in a representative sample of adolescents.

METHODS

Data on 11-19-year-old Ottawa (Canada) students (n=1147) were analyzed using self-reported information on consumption of SSBs and EDs, and time devoted to PA and ST. Multivariable logistic regression analyses were conducted to examine the associations between adherence to PA and ST recommendations and consumption of SSBs and EDs.

RESULTS

Adherence to the ST recommendation was inversely associated with consumption of SSBs [odds ratio (OR)=0.42; 95% confidence interval (CI)=0.21-0.86] and EDs (OR=0.54, 95% CI=0.31-0.92) in females only, independent of PA and relevant covariates. However, adherence to the PA recommendation was positively associated with consumption of EDs in females (OR=1.52, 95% CI=1.07-2.17) but not males, while it was not associated with consumption of SSBs in both sexes.

CONCLUSION

Among female adolescents, adherence to the ST recommendation is inversely associated with consumption of SSBs and EDs, while adherence to the PA recommendation is positively associated with consumption of EDs. Future studies should clarify the observed sex differences and determine if decreasing ST can reduce the consumption of SSBs and EDs among adolescents.

Sugar-Sweetened Beverage Consumption by Adult Caregivers and Their Children

Objective. To examine how parents’ beliefs about beverage attributes and exposure to sugar-sweetened beverage (SSB) advertising are associated with parents’ and their children’s SSB consumption. Design. Cross-sectional representative telephone survey of Philadelphia parents in households with children between the ages of 3 and 16 years. Participants. Three hundred and seventy-one randomly selected survey respondents. The response rate was 27% using the American Association for Public Opinion Research RR3 formula. Main Outcome Measures. SSB consumption, health ratings of SSBs, exposure to SSB ads, and exposure to anti-SSB public service advertisements. Analysis. Seemingly unrelated regression was used to correct for Type I error and significance levels were set at .05 or less. Results. Assessment of SSB “healthiness” was associated with the increased adult consumption of SSBs for three of the five SSBs and associated with children’s consumption for all four SSBs with child consumption data. For both groups, ratings of SSB sugar and caloric content were not related to consumption. Adult exposure to SSB-specific advertising was related to consumption for three of five SSBs and two of four SSBs consumed by children. Conclusions and Implications. These results suggest that sugar and calories are not relevant to consumption, absent an explicit connection to a healthiness evaluation of SSBs.

A nutrition/health mindset on commercial Big Data and drivers of food demand in modern and traditional systems

Building greater reciprocity between traditional and modern food systems and better convergence of human and economic development outcomes may enable the production and consumption of accessible, affordable, and appealing nutritious food for all. Information being key to such transformations, this roadmap paper offers a strategy that capitalizes on Big Data and advanced analytics, setting the foundation for an integrative intersectoral knowledge platform to better inform and monitor behavioral change and ecosystem transformation. Building upon the four P's of marketing (product, price, promotion, placement), we examine digital commercial marketing data through the lenses of the four A's of food security (availability, accessibility, affordability, appeal) using advanced consumer choice analytics for archetypal traditional (fresh fruits and vegetables) and modern (soft drinks) product categories. We demonstrate that business practices typically associated with the latter also have an important, if not more important, impact on purchases of the former category. Implications and limitations of the approach are discussed.

Substitution of sugar-sweetened beverages with other beverage alternatives: a review of long-term health outcomes

BACKGROUND

Excessive consumption of sugar-sweetened beverages (SSBs) has become an intractable public health concern worldwide, making investigation of healthy beverage alternatives for SSBs imperative.

AIM

To summarize the available evidence on the effects of replacing SSBs with beverage alternatives on long-term health outcomes.

METHOD

We systematically retrieved studies from six electronic databases from inception to November 2013. Prospective cohort studies and randomized controlled trials (RCTs) examining the effects of substituting beverage alternatives for SSBs on long-term health outcomes in both children and adults were included. The quality of included studies was assessed using the Scottish Intercollegiate Guidelines Network 50 methodology checklists.

RESULTS

Six cohort studies and four RCTs were included in the systematic review with the quality rating ranging from acceptable to high. Evidence from both cohort studies and RCTs showed substitution of SSBs by various beverage alternatives was associated with long-term lower energy intake and lower weight gain. However, evidence was insufficient to draw conclusions regarding the effect of beverage substitution on other health outcomes, and which beverage alternative is the best choice.

CONCLUSIONS

Although studies on this topic are sparse, the available evidence suggests a potential beneficial effect on body weight outcomes when SSBs are replaced by water or low-calorie beverages. Further studies in this area are warranted to fully understand the long-term health implications of beverage substitutions.

An overview of the nutrition transition in West Africa: implications for non-communicable diseases

The nutrition landscape in West Africa has been dominated by the programmes to address undernutrition. However, with increasing urbanisation, technological developments and associated change in dietary patterns and physical activity, childhood and adult overweight, and obesity are becoming more prevalent. There is an evidence of increasing intake of dietary energy, fat, sugars and protein. There is low consumption of fruit and vegetables universally in West Africa. Overall, the foods consumed are predominantly traditional with the component major food groups within recommended levels. Most of the West African countries are at the early stages of nutrition transition but countries such as Cape Verde, Ghana and Senegal are at the latter stages. In the major cities of the region, children consume energy-dense foods such as candies, ice cream and sweetened beverages up to seven times as frequently as fruit and vegetables. Adult obesity rates have increased by 115 % in 15 years since 2004. In Ghana, the prevalence of overweight/obesity in women has increased from 12·8 % in 1993 to 29·9 % in 2008. In Accra, overweight/obesity in women has increased from 62·2 % in 2003 to 64·9 % in 2009. The age-standardised proportion of adults who engage in adequate levels of physical activity ranges from 46·8 % in Mali to 94·7 % in Benin. The lingering stunting in children and the rising overweight in adults have resulted to a dual burden of malnutrition affecting 16·2 % of mother-child pairs in Cotonou. The prevalence of hypertension has been increased and ranges from 17·6 % in Burkina Faso to 38·7 % in Cape Verde. The prevalence is higher in the cities: 40·2 % in Ougadougou, 46·0 % in St Louis and 54·6 % in Accra. The prevalence of diabetes ranges from 2·5 to 7·9 % but could be as high as 17·9 % in Dakar, Senegal. The consequences of nutrition transition are not only being felt by the persons in the high socioeconomic class, but also in cities such as Accra and Ouagadougou, where at least 19 % of adults from the poorest households are overweight and 19-28 % have hypertension. Concerted national action involving governments, partners, private sector and civil society is needed to re-orient health systems and build capacity to address the dual burden of malnutrition, to regulate the food and beverage industry and to encourage healthy eating throughout the life course.

Do sugar-sweetened beverages cause adverse health outcomes in adults? A systematic review protocol

BACKGROUND

Chronic diseases, such as cardiovascular disease and type 2 diabetes, impose significant burden to public health. Most chronic diseases are associated with underlying preventable risk factors, such as elevated blood pressure, blood glucose, and lipids, physical inactivity, excessive sedentary behaviours, overweight and obesity, and tobacco usage. Sugar-sweetened beverages are known to be significant sources of additional caloric intake, and given recent attention to their contribution in the development of chronic diseases, a systematic review is warranted. We will assess whether the consumption of sugar-sweetened beverages in adults is associated with adverse health outcomes and what the potential moderating factors are.

METHODS/DESIGN

Of interest are studies addressing sugar-sweetened beverage consumption, taking a broad perspective. Both direct consumption studies as well as those evaluating interventions that influence consumption (e.g. school policy, educational) will be relevant. Non-specific or multi-faceted behavioural, educational, or policy interventions may also be included subject to the level of evidence that exists for the other interventions/exposures. Comparisons of interest and endpoints of interest are pre-specified. We will include randomized controlled trials, controlled clinical trials, interrupted time series studies, controlled before-after studies, prospective and retrospective comparative cohort studies, case-control studies, and nested case-control designs. The MEDLINE, Embase, The Cochrane Library, CINAHL, ERIC, and PsycINFO databases and grey literature sources will be searched. The processes for selecting studies, abstracting data, and resolving conflicts are described. We will assess risk of bias using design-specific tools. To determine sets of confounding variables that should be adjusted for, we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessments. Meta-analysis will be conducted where appropriate; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used for determining the quality of evidence for outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009638.

Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol

BACKGROUND

Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide. Most chronic diseases are associated with underlying preventable risk factors, such as elevated blood pressure, high blood glucose or glucose intolerance, high lipid levels, physical inactivity, excessive sedentary behaviours, and overweight/obesity. The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood. Sugar-sweetened beverages are known to be significant sources of additional caloric intake, and given recent attention to their contribution in the development of chronic diseases, a systematic review is warranted. We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are.

METHODS/DESIGN

Of interest are studies addressing sugar-sweetened beverage consumption, taking a broad perspective. Both direct consumption studies as well as those evaluating interventions that influence consumption (e.g. school policy, educational) will be relevant. Non-specific or multi-faceted behavioural, educational, or policy interventions may also be included subject to the level of evidence that exists for the other interventions/exposures. Comparisons of interest and endpoints of interest are pre-specified. We will include randomized controlled trials, controlled clinical trials, interrupted time series studies, controlled before-after studies, prospective and retrospective comparative cohort studies, case-control studies, and nested case-control designs. The MEDLINE®, Embase, The Cochrane Library, CINAHL, ERIC, and PsycINFO® databases and grey literature sources will be searched. The processes for selecting studies, abstracting data, and resolving conflicts are described. We will assess risk of bias using design-specific tools. To determine sets of confounding variables that should be adjusted for, we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessments. Meta-analysis will be conducted where appropriate; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach will be used to determine the quality of evidence for outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42014009641.

The school nutrition environment and its association with soft drink intakes in seven countries across Europe--the ENERGY project

The school is an important setting for promoting healthy eating especially at the transition from childhood to adolescence. This study contributes to the literature by describing practices within physical, political and sociocultural aspects of the school nutrition environment in seven countries across Europe based on questionnaires to the school management, and exploring their associations with soft drink consumption reported on questionnaires by 10-12 year olds. Several of the commonly self-reported practices could be supportive of a healthy diet (time to eat, access to water, restriction on marketing), but some practices were underutilized (i.e. discussion with stakeholders, healthy foods at events). Only a few associations of practices with the pupils׳ soft drink consumption were found.

Sugar-sweetened beverage intake and cancer recurrence and survival in CALGB 89803 (Alliance)

Background

In colon cancer patients, obesity, sedentary lifestyle, and high dietary glycemic load have been associated with increased risk of cancer recurrence. High sugar-sweetened beverage intake has been associated with obesity, diabetes, and cardio-metabolic diseases, but the influence on colon cancer survival is unknown.

Methods

We assessed the association between sugar-sweetened beverage consumption on cancer recurrence and mortality in 1,011 stage III colon cancer patients who completed food frequency questionnaires as part of a U.S. National Cancer Institute-sponsored adjuvant chemotherapy trial. Hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated with Cox proportional hazard models.

Results

Patients consuming ≥2 servings of sugar-sweetened beverages per day experienced an adjusted HR for disease recurrence or mortality of 1.67 (95% CI, 1.04–2.68), compared with those consuming <2 servings per month (P_trend = 0.02). The association of sugar-sweetened beverages on cancer recurrence or mortality appeared greater among patients who were both overweight (body mass index ≥25 kg/m²) and less physically active (metabolic equivalent task-hours per week <18) (HR = 2.22; 95% CI, 1.29–3.81, P_trend = 0.0025).

Conclusion

Higher sugar-sweetened beverage intake was associated with a significantly increased risk of cancer recurrence and mortality in stage III colon cancer patients.

Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose-response meta-analysis of prospective studies

The intake of sugar-sweetened soft drinks has been reported to be associated with an increased risk of type 2 diabetes, but it is unclear whether this is because of the sugar content or related lifestyle factors, whether similar associations hold for artificially sweetened soft drinks, and how these associations are related to BMI. We aimed to conduct a systematic literature review and dose-response meta-analysis of evidence from prospective cohorts to explore these issues. We searched multiple sources for prospective studies on sugar-sweetened and artificially sweetened soft drinks in relation to the risk of type 2 diabetes. Data were extracted from eleven publications on nine cohorts. Consumption values were converted to ml/d, permitting the exploration of linear and non-linear dose-response trends. Summary relative risks (RR) were estimated using a random-effects meta-analysis. The summary RR for sugar-sweetened and artificially sweetened soft drinks were 1·20/330 ml per d (95 % CI 1·12, 1·29, P< 0·001) and 1·13/330 ml per d (95 % CI 1·02, 1·25, P= 0·02), respectively. The association with sugar-sweetened soft drinks was slightly lower in studies adjusting for BMI, consistent with BMI being involved in the causal pathway. There was no evidence of effect modification, though both these comparisons lacked power. Overall between-study heterogeneity was high. The included studies were observational, so their results should be interpreted cautiously, but findings indicate a positive association between sugar-sweetened soft drink intake and type 2 diabetes risk, attenuated by adjustment for BMI. The trend was less consistent for artificially sweetened soft drinks. This may indicate an alternative explanation, such as lifestyle factors or reverse causality. Future research should focus on the temporal nature of the association and whether BMI modifies or mediates the association.

Reviews examining sugar-sweetened beverages and body weight: correlates of their quality and conclusions

BACKGROUND

The role of sugar-sweetened beverages (SSBs) in increasing obesity is of great scientific, clinical, and public health interest. Many reviews have been published on this topic in recent years with very different conclusions.

OBJECTIVE

We sought to assess the scientific quality and other characteristics that may be associated with the conclusions of reviews regarding the causal relation between SSB consumption and body weight.

DESIGN

A systematic search of reviews in English language-published peer-reviewed journals in 2006-2013 was performed. Their methodologic quality was assessed by 2 judges using 2 scoring systems: the Assessment of Multiple Systematic Reviews and the American Dietetic Association Quality Criteria Checklist. The conclusions were blindly assessed by 11 independent readers using a Likert scale ranging from a position score of 0 = no evidence of a causal relation to 5 = strong evidence of a causal relation.

RESULTS

Twenty reviews were identified: 5 meta-analyses, 3 qualitative systematic reviews, and 12 qualitative nonsystematic reviews. Four received funding from the food industry. Quality scores were neither correlated with the readers' perception of conclusions nor with the source of funding. However, industry-funded reviews were more likely to suggest that evidence supporting a causal relation between SSB consumption and weight gain was weak (mean position score = 1.78), whereas evidence was generally considered well-founded in other reviews (mean position score = 3.39; P ≤ 0.01).

CONCLUSIONS

For a complex and controversial scientific issue, it is important to minimize perceived or actual threats to scientific objectivity and methodologic quality. More refined tools are needed to better assess their scientific quality and to identify factors and mechanisms that may influence authors' conclusions.

Butorphanol prevents morphine-induced pruritus without increasing pain and other side effects: a systematic review of randomized controlled trials

PURPOSE

Pruritus is a frequent adverse event after administration of morphine. Butorphanol has been used to prevent morphine-induced pruritus, but its efficacy is still controversial. The aim of this systematic review was to evaluate the efficacy of using butorphanol to prevent morphine-induced pruritus.

SOURCE

We searched PubMed, Cochrane Library, EMBASE, and China's BioMedical Disc for full reports of randomized controlled trials that compared the use of butorphanol with either placebo or no treatment for preventing morphine-induced pruritus. The number of patients experiencing pruritus or other side effects was analyzed using relative risk (RR) with 95% confidence intervals (CI).

PRINCIPAL FINDINGS

Sixteen trials (795 patients) were analyzed. Continuous intravenous and epidural butorphanol reduced pruritus with RR 0.22 (95% CI 0.10 to 0.45) and RR 0.24 (95% CI 0.16 to 0.36), respectively. Use of epidural butorphanol decreased the number of patients requesting rescue treatment for pruritus (RR 0.57; 95% CI 0.41 to 0.81). Butorphanol decreased postoperative pain intensity at four, eight, and 12 hr with standardized mean differences of -0.29 (95% CI -0.52 to -0.05), -0.30 (95% CI -0.56 to -0.04), and -0.23 (95% CI -0.46 to -0.01), respectively. Epidural but not intravenous butorphanol reduced postoperative nausea and vomiting (PONV) (RR 0.35; 95% CI 0.19 to 0.66). Butorphanol did not increase respiratory depression (RR 0.71; 95% CI 0.31 to 1.63), somnolence (RR 0.71; 95% CI 0.22 to 2.37), or dizziness (RR 2.45; 95% CI 0.35 to 17.14).

CONCLUSION

Butorphanol administered with morphine may be an effective strategy for preventing morphine-induced pruritus as it decreases pain intensity and PONV without increasing other side effects. Thus, it can be recommended for preventing morphine-induced pruritus during the perioperative period.

Current evidence on healthy eating

Large nutritional epidemiology studies, with long-term follow-up to assess major clinical end points, coupled with advances in basic science and clinical trials, have led to important improvements in our understanding of nutrition in primary prevention of chronic disease. Although much work remains, sufficient evidence has accrued to provide solid advice on healthy eating. Good data now support the benefits of diets that are rich in plant sources of fats and protein, fish, nuts, whole grains, and fruits and vegetables; that avoid partially hydrogenated fats; and that limit red meat and refined carbohydrates. The simplistic advice to reduce all fat, or all carbohydrates, has not stood the test of science; strong evidence supports the need to consider fat and carbohydrate quality and different protein sources. This article briefly summarizes major findings from recent years bearing on these issues.

Uric acid-induced endothelial dysfunction is associated with mitochondrial alterations and decreased intracellular ATP concentrations

BACKGROUND/AIMS

Endothelial dysfunction is associated with mitochondrial alterations. We hypothesized that uric acid (UA), which can induce endothelial dysfunction in vitro and in vivo, might also alter mitochondrial function.

METHODS

Human aortic endothelial cells were exposed to soluble UA and measurements of oxidative stress, nitric oxide, mitochondrial density, ATP production, aconitase-2 and enoyl Co-A hydratase-1 expressions, and aconitase-2 activity in isolated mitochondria were determined. The effect of hyperuricemia induced by uricase inhibition in rats on renal mitochondrial integrity was also assessed.

RESULTS

UA-induced endothelial dysfunction was associated with reduced mitochondrial mass and ATP production. UA also decreased aconitase-2 activity and lowered enoyl CoA hydratase-1 expression. Hyperuricemic rats showed increased mitDNA damage in association with higher levels of intrarenal UA and oxidative stress.

CONCLUSIONS

UA-induced endothelial dysfunction is associated with mitochondrial alterations and decreased intracellular ATP. These studies provide additional evidence for a deleterious effect of UA on vascular function that could be important in the pathogenesis of hypertension and vascular disease.

Sugar-sweetened beverages and genetic risk of obesity

BACKGROUND

Temporal increases in the consumption of sugar-sweetened beverages have paralleled the rise in obesity prevalence, but whether the intake of such beverages interacts with the genetic predisposition to adiposity is unknown.

METHODS

We analyzed the interaction between genetic predisposition and the intake of sugar-sweetened beverages in relation to body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) and obesity risk in 6934 women from the Nurses' Health Study (NHS) and in 4423 men from the Health Professionals Follow-up Study (HPFS) and also in a replication cohort of 21,740 women from the Women's Genome Health Study (WGHS). The genetic-predisposition score was calculated on the basis of 32 BMI-associated loci. The intake of sugar-sweetened beverages was examined prospectively in relation to BMI.

RESULTS

In the NHS and HPFS cohorts, the genetic association with BMI was stronger among participants with higher intake of sugar-sweetened beverages than among those with lower intake. In the combined cohorts, the increases in BMI per increment of 10 risk alleles were 1.00 for an intake of less than one serving per month, 1.12 for one to four servings per month, 1.38 for two to six servings per week, and 1.78 for one or more servings per day (P<0.001 for interaction). For the same categories of intake, the relative risks of incident obesity per increment of 10 risk alleles were 1.19 (95% confidence interval [CI], 0.90 to 1.59), 1.67 (95% CI, 1.28 to 2.16), 1.58 (95% CI, 1.01 to 2.47), and 5.06 (95% CI, 1.66 to 15.5) (P=0.02 for interaction). In the WGHS cohort, the increases in BMI per increment of 10 risk alleles were 1.39, 1.64, 1.90, and 2.53 across the four categories of intake (P=0.001 for interaction); the relative risks for incident obesity were 1.40 (95% CI, 1.19 to 1.64), 1.50 (95% CI, 1.16 to 1.93), 1.54 (95% CI, 1.21 to 1.94), and 3.16 (95% CI, 2.03 to 4.92), respectively (P=0.007 for interaction).

CONCLUSIONS

The genetic association with adiposity appeared to be more pronounced with greater intake of sugar-sweetened beverages. (Funded by the National Institutes of Health and others.).

Consumption of sugar-sweetened beverages in relation to the metabolic syndrome among Iranian adults

BACKGROUND

Few data are available linking intake of sugar-sweetened beverages (SSBs) with the metabolic syndrome. Furthermore, findings from these studies are inconsistent and most are from Western societies; no information is available in this regard from Middle Eastern populations.

OBJECTIVE

This study was conducted to assess the relationship between SSB consumption and metabolic syndrome in an Iranian adult population.

METHODS

In this cross-sectional study, data from 1,752 people (782 men and 970 women) that were selected with the multistage cluster random sampling method from three counties of Isfahan, Najafabad and Arak were used. A validated food frequency questionnaire was used to assess participants' usual dietary intakes. Consumption of SSBs was calculated by summing up the consumption of 'soft drinks' and 'artificially sweetened fruit juices'. To categorize participants, we used three levels of SSB consumption: <1 time/week, 1-3 times/week, and >3 times/week. Biochemical assessments were done after an overnight fasting. Metabolic syndrome was defined according to the guidelines of Adult Treatment Panel III.

RESULTS

Subjects with high consumption of SSBs (>3 times/week) were younger than those with low consumption (<1 time/week). Mean BMI was not significantly different across SSB categories. High consumption of SSBs was associated with greater intakes of energy and almost all food groups. We found a significant difference in serum triglyceride levels between men consuming SSBs 1-3 times/week and those consuming <1 time/week. However, after controlling for potential confounders, this association disappeared. In crude models, no significant associations were found between SSB intake and prevalence of the metabolic syndrome in either gender. After adjustment for potential confounders including BMI, we found that men in the top category of SSB intake were 17% more likely to have the metabolic syndrome (odds ratio (OR) 1.17; 95% confidence interval (95% CI) 0.56-2.46), while women in the highest category were 20% less likely to have the syndrome (OR 0.80; 95% CI 0.46-1.42) as compared with those in the bottom category. However, these associations were not significant in either men or women.

CONCLUSION

Our results do not support the previous findings on the association between SSB consumption and metabolic syndrome. Prospective studies are needed to further explore for this association.