REVIEW URRENT C OPINION
Sugar-sweetened beverages and body weight Cara B. Ebbeling
Purpose of review Given the high prevalence of obesity in the USA, much recent attention has focused on dietary strategies for weight control. Several medical and scientific societies currently recommend reducing consumption of sugar-sweetened beverages (SSBs). However, the evidence base for a public health recommendation has been a topic of debate. The purpose of this review is not to underscore the debate but rather to consider how recently published data pertaining to SSBs contribute to the evidence base for preventing and treating obesity, with application to caring for patients. Recent findings Consumption of SSBs remains prevalent in the USA. Emerging data from epidemiological studies and clinical trials indicate that consumption contributes to positive energy balance and reducing consumption has beneficial effects on body weight. Some individuals may be more susceptible to the adverse effects of consuming SSBs owing to their ethnicity or genetic predisposition. Plausible physiological mechanisms link consumption of SSBs with weight control. Summary Available data provide an evidence base for counselling patients to reduce consumption of SSBs. Nevertheless, additional research is needed to strengthen the evidence base, particularly studies aimed at understanding susceptibility to the adverse effects of consuming SSBs on body weight and mechanisms for these effects. Keywords BMI, dietary counselling, nutrition, obesity, sugar-sweetened beverages
INTRODUCTION Recently, much attention has been directed towards the evidence base for a recommendation to limit consumption of sugar-sweetened beverages (SSBs), as a dietary strategy for preventing and treating obesity. An evidence-based approach to establishing dietary guidelines or providing medical nutrition therapy relies on reviewing and evaluating available data; determining the strength of inference drawn from the data; and integrating data with nutrition expertise, sound judgement and perspectives of individuals for whom a recommendation may affect health [1]. Ongoing debate regarding a public health recommendation to limit consumption of SSBs stems largely from differences in opinion on evaluating and drawing inferences from available data [2,3]. The purpose of this review is not to underscore the debate but rather to consider how recently published data pertaining to SSBs contribute to the evidence base for preventing and treating obesity, with application to caring for patients. The following vignette provides a backdrop and context for highlighting some of the most important and interesting articles published between 1 January 2012
and 31 August 2013 that address a series of questions regarding SSBs.
VIGNETTE J.D. is a 14-year-old boy who weighs 105.1 kg and stands 173.5 cm tall. As such, his BMI is 34.9 kg/m2 and exceeds the 99th percentile for sex and age. He reports Hispanic ethnicity. Both of his parents are obese (BMI >30 kg/m2). His only sister has a BMI at the 49th percentile. J.D.’s fasting blood glucose is within normal limits (89 mg/dl), but his fasting insulin is elevated (68.3 mIU/ml). His blood lipid profile indicates total cholesterol (148 mg/dl) and LDL cholesterol (80 mg/dl) within normal limits but New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital, Boston, Massachusetts, USA Correspondence to Cara B. Ebbeling, PhD, New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital, 300 Longwood Avenue (AU307), Boston, MA 02115, USA. Tel: +1 617 919 3457; fax: +1 617 730 0183; e-mail: [email protected] Curr Opin Lipidol 2014, 25:1–7 DOI:10.1097/MOL.0000000000000035
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KEY POINTS Consumption of SSBs is prevalent in the USA, with average consumption equating to approximately 150 kcal per day. Data from well conducted prospective observational studies indicate a significant relationship between consumption of SSBs and weight gain in children and adults. Two recent randomized controlled trials provide convincing evidence that reducing consumption of SSBs has beneficial effects on body weight. Ethnicity or genetics may influence susceptibility to the effects of consuming SSBs on body weight. Emerging data contribute to the evidence base for a recommendation to reduce consumption of SSBs, consistent with statements from several medical and academic societies.
low HDL cholesterol (32.8 mg/dl) and elevated triglycerides (173 mg/dl). His serum alanine aminotransferase (ALT) is slightly elevated (33 U/l). J.D. plays basketball three times per week in an afterschool league at a community centre. He reports a diet high in carbohydrate (mostly from refined sources), with adequate protein but minimal attention to vegetables and fruits. He also reports consuming a large glass of fruit punch for breakfast and his favourite brand of sports drinks when thirsty during basketball practice. All family members express the importance of health but are overwhelmed with changing their dietary habits.
WHAT ARE SUGAR-SWEETENED BEVERAGES? WHAT SUGAR-SWEETENED BEVERAGES CONTRIBUTE THE MOST TO ENERGY INTAKE? SSBs are termed ‘soft’ drinks, as opposed to alcoholic beverages that are considered ‘hard’ according to this jargon. Examples of SSBs include conventional carbonated beverages, or sodas, and noncarbonated beverages such as fruit drinks, enhanced waters, highly sweetened coffees and teas, sports drinks and energy drinks. These beverages typically are sweetened with high-fructose corn syrup (55% fructose and 45% glucose in monomeric form) or sucrose (50% fructose and 50% glucose in dimeric form) and provide between approximately 100 and 170 kcal per 12 fluid ounces. Sports drinks contain special formulations of electrolytes (sodium, potassium, calcium, magnesium), originally designed to replenish losses in sweat during intensive endurance 2
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events. Energy drinks are distinct from sports drinks and contain stimulants (most notably, large amounts of caffeine) and other ingredients alleged to enhance mental acuity and physical performance [4,5]. Data from the National Health and Nutrition Examination Survey (NHANES) indicate that the most prevalent sources of energy from SSBs are fruit drinks among children and sodas among adolescents and adults [6]. The contribution of fruit drinks and sodas to energy intake decreased modestly between 1999–2000 and 2007–2008 [6,7]. However, despite this decrease, average consumption of SSBs still equated to approximately 150 kcal per day in 2009–2010 [7], and the contribution of sports and energy drinks to energy intake increased among adolescents and adults over the last decade [6]. The relative contribution of sports vs. energy drinks to this increase is not well defined. Further discussion regarding the distinct adverse health effects of energy drinks [8,9] is beyond the scope of this review. Consuming sports drinks may be viewed as consistent with a healthful lifestyle, possibly due to advertising campaigns that feature famous athletes [10]. However, although athletes who are involved in intensive endurance events may benefit from sports drinks [11], choosing these products over water is unwarranted for most individuals engaged in routine or recreational physical activity. In a prospective cohort study (Growing Up Today Study II, 2004–2011) [12] of over 10 000 adolescents, intake of sports drinks was linked to greater increase in BMI (0.03 kg/m2 per serving per week, P ¼ 0.002), thereby contributing to weight gain much like other SSBs (discussed below).
DOES CONSUMPTION OF SUGARSWEETENED BEVERAGES CONTRIBUTE TO WEIGHT GAIN AND ADIPOSITY? The preponderance of epidemiological data from prospective cohort studies indicate a significant relationship between consumption of SSBs and weight gain, as summarized in previous reviews [2,13,14]. Recently published data contribute to the evidence base for this relationship in children and adults. DeBoer et al. [15 ] evaluated young children who were part of a nationally representative sample born in 2001 in the USA. They reported that those who drank SSBs regularly (at least one serving per day) at 2 years of age, compared with their counterparts who consumed less than one serving per day, gained more weight by 4 years of age as indicated by a greater increase in BMI z score over time (P < 0.05). At 5 years of age, habitual consumers had a higher odds of being obese (odds &
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ratio 1.43, P < 0.01) based on a cross-sectional analysis [15 ]. With regard to adults, Pan et al. [16 ] analysed pooled data from three large prospective cohort studies including the Nurses’ Health Study (NHS, 1986–2006), NHS II (1991–2007) and Health Professionals Follow-up Study (HPFS, 1986– 2006). Daily consumption of SSBs was associated with weight gain of 0.36 kg per serving over each 4-year period. Given that every one-cup increment of water consumed per day was associated with weight loss of 0.13 kg over each period, replacement of one serving of SSBs by one cup of water per day would be associated with 2.45 kg less weight gain over 20 years (0.49 kg per 4-year time period). The estimated substitution benefit was attributed to a decrease in total energy intake [16 ]. Results from short-term intervention studies are generally consistent with epidemiological data, suggesting that consumption of SSBs, compared with a control condition, contributes to weight gain. Although the magnitude and significance of weight gain differs across studies, a recently updated meta-analysis indicated a significant overall effect [3,17]. Concerning adiposity, Maersk et al. [18 ] reported that study participants who were instructed to drink 1 liter of sugar-sweetened cola per day had greater increases in liver, skeletal muscle and visceral fat than those who consumed the same volume of other beverages (milk, diet cola sweetened with aspartame or water) over 6 months, despite no differences for change in body weight or total fat mass. These findings suggest an increased risk for chronic diseases (discussed below) associated with regional adiposity. &
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WILL REDUCING CONSUMPTION OF SUGAR-SWEETENED BEVERAGES HAVE A BENEFICIAL EFFECT ON BODY WEIGHT? Data from randomized controlled trials on the effect of interventions aimed at reducing consumption of SSBs on body weight have emerged slowly over the last decade. Intervention effects include decreased rates of obesity among schoolchildren [19], decreased BMI among overweight or obese adolescents [20] and increased likelihood of substantial weight loss among adults [21]. However, in each of the cited studies, change in BMI or body weight was not significant among the full cohort of participants. Two recent and arguably more definitive randomized controlled trials contribute important data to the evidence base pertaining to the question at hand [22 ,23 ]. In both of these studies, participants regularly consumed SSBs prior to random assignment, and the primary aim was to evaluate the effect of reducing consumption on BMI. &&
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Ebbeling et al. [22 ] randomly assigned 224 overweight and obese adolescents to intervention and control groups for 2 years. Retention rates were 97% at 1 year and 93% at 2 years. Participants in the intervention group received home deliveries of noncaloric beverages, including water and artificially sweetened (’diet’) beverages, for 1 year. Reported consumption of SSBs dropped to almost nothing with the intervention. Significant between-group differences for changes in BMI (0.57, P ¼ 0.045) and body weight (1.9 kg, P ¼ 0.04) were observed over this time period, due to a smaller increase in BMI in the intervention group compared with the control group. After an additional 1-year follow-up period without home deliveries, changes in BMI (0.30; P ¼ 0.46) and body weight (0.8, P ¼ 0.55) did not differ between the two groups. This finding is consistent with a previous study showing that discontinuation of an intervention extinguishes group effects [24]. The data obtained at 1 year reflect the effects of an active intervention and arguably are more relevant in addressing the question at hand. de Ruyter et al. [23 ] randomly assigned 641 schoolchildren, aged 4–11 years, to receive one serving (250 ml) per day of a sugar-free beverage, sweetened with sucralose and acesulfame potassium, or a similar SSB containing 104 kcal. The completion rate was 74% at 18 months. The two beverages were formulated to be indistinguishable with regard to sweetness and packaging, and the trial was conducted according to a double-blind design. The group difference for a change in BMI z score was significant, given a smaller increase with consumption of the sugar-free beverage than with the SSB [0.02 vs. 0.15 units; 95% confidence interval (CI) of the difference, 0.21 to 0.05]. Likewise, weight increased less with consumption of the sugar-free beverage compared with the SSB (6.35 vs. 7.37 kg; 95% CI for the difference, 1.54 to 0.48). Fat mass also increased less in the group consuming the sugar-free beverage. &&
ARE SOME INDIVIDUALS PARTICULARLY SUSCEPTIBLE TO THE EFFECT OF CONSUMING SUGAR-SWEETENED BEVERAGES ON BODY WEIGHT? &&
Data from recent studies suggest that ethnicity [22 ] or genetics [25 ] may influence susceptibility. Evidence of effect modification by ethnic group was noted in the aforementioned study by Ebbeling et al. [22 ]. Among Hispanic participants, the difference in BMI between the intervention and control groups was significant following 1 year of home deliveries of noncaloric beverages (1.79, P ¼ 0.007) and after an additional 1-year follow-up period (2.35, P ¼ 0.01). The group effect was not
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significant among non-Hispanic participants. Reanalysis of data from a 19-month prospective observational study of 548 middle-school students [26] also showed effect modification by ethnic group (P ¼ 0.007), with a strong association between change in consumption of SSBs and change in BMI for the Hispanics but no association for the non-Hispanics [22 ]. The reason for effect modification by ethnic group remains hypothetical and may involve differences in insulin secretion following sugar consumption [27–29], genetic susceptibility [25 ] and other factors influencing disparities in BMI such as socioeconomic status and early feeding behaviours [30]. Qi et al. [25 ] recently reported that frequent consumption of SSBs modified the genetic risk of obesity in three large cohorts of individuals from European ancestry. Researchers quantified genetic risk using a predisposition score based on 32 singlenucleotide polymorphisms, with each point of the score corresponding to one risk allele. On the basis of data from the NHS (18 years of follow-up) and HPFS (12 years of follow-up), the relative risk of incident obesity for each increment of 10 risk alleles was 5.06 (95% CI, 1.66–15.5) for consumption of one or more servings of SSBs per day, compared with 1.19 (95% CI, 0.90–1.59) for consumption of less than one serving per month. Findings from an independent large cohort of women (Women’s Genome Health Study, 6 years of follow-up) were similar [25 ]. These data suggest that consumption of SSBs may exacerbate weight gain among genetically susceptible individuals, and reducing consumption may attenuate genetic predisposition. However, whether these findings are generalizable to other ethnic-racial groups requires additional research. &&
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WHAT ARE THE MECHANISMS BY WHICH SUGAR-SWEETENED BEVERAGES MAY EXERT AN ADVERSE EFFECT ON BODY WEIGHT? Plausible mechanisms involve postprandial hyperglycemia, rapid absorption of fructose and lessened satiety. When SSBs are consumed in large amounts, particularly without other foods containing protein and fat to attenuate the carbohydrate-induced rise in blood glucose, rapid absorption of glucose has the potential to cause postprandial hyperglycemia that initiates a cascade of events. These include an increase in circulating insulin relative to glucagon, glucose uptake by insulin-sensitive tissues, a subsequent drop in blood glucose to concentrations below fasting levels, increased hunger due to limited fuel availability and overeating [31]. In contrast to 4
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glucose, fructose is metabolized primarily in the liver. Rapid absorption of fructose from SSBs may overwhelm hepatic metabolic pathways, fuel denovo lipogenesis and cause physiological aberrations such as excess fat deposition and insulin resistance [32,33]. With regard to lessened satiety, consumption of energy in liquid vs. solid form may lead to incomplete compensatory reductions in energy intake from other sources and thereby positive energy balance [34]. However, the strength of evidence for each of these mechanisms remains open to debate [3,35,36].
DOES CONSUMPTION OF SUGARSWEETENED BEVERAGES AFFECT RISK FOR OBESITY-RELATED CHRONIC DISEASES? Although not the primary focus of this review, the link between consumption of SSBs and risk for obesity-related chronic diseases is an important consideration when building context for dietary counselling. Findings from prospective cohort studies indicate significant associations between consumption of SSBs and incidence of metabolic syndrome [37,38], type 2 diabetes [37] and coronary heart disease [39,40]. Moreover, consumption has been associated, either in longitudinal or cross-sectional analyses, with individual components and clinical manifestations of the metabolic syndrome. These include increased waist circumference [38,41], impaired fasting glucose [38], increased blood levels of triglycerides [38,39,41,42], decreased levels of HDL cholesterol [38,39,41], elevated blood pressure [38,42], increased levels of biomarkers for chronic inflammation [39] and indicators of nonalcoholic fatty liver disease including ALT [43]. Controlling for body weight attenuates without fully extinguishing some of these associations [37,40,41], suggesting weight-dependent and weight-independent pathways linking consumption of SSBs with chronic diseases.
REVISITING THE VIGNETTE Drawing inference from the evidence base, a recommendation to reduce consumption of SSBs, is appropriate for patients such as J.D. who are overweight or obese. Hispanic ethnicity, family history of obesity and a profile of laboratory values consistent with metabolic aberrations linked with consumption of SSBs provide additional context for the recommendation. Nevertheless, several questions, in addition to those posed above, are likely to surface when negotiating plans to reduce consumption of SSBs. Volume 25 Number 1 February 2014
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Why do patients consume sugar-sweetened beverages? There are many reasons, with taste being foremost [44 ,45]. Branding may influence taste preferences and beverage choices for patients such as J.D. [44 ]. Strong preferences for the tastes of favourite brands likely develop through habitual consumption [46,47], leading to excessive stimulation of taste receptors on the tongue that cause a rewarding sensation. Consistent with this line of reasoning, a neuroimaging study conducted by Burger and Stice [48 ] indicated activation of taste and reward regions of the brain in response to consumption of a branded soft drink. Among habitual consumers, the brand logo elicited a response in a region of the brain thought to encode salience or attention to cues [48 ]. &
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What type of education would prompt patients to recognize a need for reducing consumption of sugar-sweetened beverages? Adolescents and young adults often dismiss the adverse effects of consumption on their personal health [44 ]. Education concerning these effects likely is an important component of an intervention for patients such as J.D. During focus groups conducted by Block et al. [44 ], young adults suggested that health messages with shock appeal and graphical representation of information would get their attention. Under the theme of Think Before You Drink, Ebbeling et al. [22 ] provided an interactive educational programme that covered topics such as sugar content of popular beverages; importance of drinking unsweetened water for hydration; possible effects of SSBs in promoting excess energy intake, weight gain, tooth decay, hunger and lethargy; and caution with regard to misleading beverage labels and advertisements. &
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patients such as J.D. Although parents may express concern over depriving normal weight siblings of their favourite SSBs, such concern can be addressed with evidence that avoiding SSBs prevents excessive weight gain over the long term among individuals who are not overweight or obese [16 ]. &
Is a focus on sugar-sweetened beverages too narrow when counselling patients around weight control? Of course, SSBs are not the only sources of refined carbohydrate, and many dietary behaviours contribute to obesity [49,50]. Nevertheless, for patients such as J.D. who are overwhelmed when attempting to change dietary behaviours, a recommendation to reduce consumption of SSBs is a reasonable first step in light of the evidence base documenting measureable and beneficial effects of reduced consumption on body weight. Such a recommendation is arguably less confusing than other dietary intervention messages, especially in that an ideal replacement for SSBs is simply unsweetened water. Over time and depending on patient readiness, a practitioner can expand the focus of nutrition education and dietary counselling to recommend increased consumption of healthful foods (vegetables, whole grains, fruits) and reduced consumption of foods that, along with SSBs, are components of unhealthful dietary patterns [51].
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What support do patients need from other people to reduce consumption of sugar-sweetened beverages? In addition to strong taste preferences, ready availability of SSBs at home and the influence of parents or peers who purchase and consume SSBs are potentially important determinants of consumption [10,45]. Provision of noncaloric beverages, education (discussed above) and respectful counselling on strategies for overcoming environmental and social factors that facilitate consumption of SSBs are effective strategies when used in combination for promoting reduced consumption [20,22 ]. Removing SSBs from the home, providing noncaloric beverages (including safe tap water) [10] and modelling consumption of noncaloric beverages are arguably among the most important types of support that family members can provide for &&
CONCLUSION Current debate need not detract from a recommendation to reduce consumption of SSBs. Indeed, statements from several medical and academic societies encourage reduced consumption for controlling body weight and risk for obesity-related chronic diseases [52,53]. Findings presented in recent articles provide support for these statements and contribute to the expanding evidence base for a recommendation to reduce consumption of SSBs in efforts aimed at obesity prevention and treatment. Additional research is needed to strengthen the evidence base, particularly studies aimed at understanding susceptibility to the adverse effects of consuming SSBs on body weight and mechanisms for these effects. Acknowledgements Dr Ebbeling has received funding from the National Institutes of Health to study the effect of consuming SSBs on body weight. Conflicts of interest There are no conflicts of interest.
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REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA 2008; 300:1814–1816. 2. Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugarsweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013; 14:606–619. 3. Kaiser KA, Shikany JM, Keating KD, Allison DB. Will reducing sugar-sweetened beverage consumption reduce obesity? Evidence supporting conjecture is strong, but evidence when testing effect is weak. Obes Rev 2013; 14:620–633. 4. Campbell B, Wilborn C, La Bounty P, et al. International Society of Sports Nutrition position stand: energy drinks. J Int Soc Sports Nutr 2013; 10:1. 5. Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics 2011; 127:1182–1189. 6. Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. J Acad Nutr Diet 2013; 113:43–53. 7. Kit BK, Fakhouri TH, Park S, et al. Trends in sugar-sweetened beverage consumption among youth and adults in the United States. Am J Clin Nutr 2013; 98:180–188. 8. Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011; 127:511–528. 9. Jackson DA, Cotter BV, Merchant RC, et al. Behavioral and physiologic adverse effects in adolescent and young adult emergency department patients reporting use of energy drinks and caffeine. Clin Toxicol (Phila) 2013; 51:557–565. 10. Bogart LM, Cowgill BO, Sharma AJ, et al. Parental and home environmental facilitators of sugar-sweetened beverage consumption among overweight and obese latino youth. Acad Pediatr 2013; 13:348–355. 11. Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand. Nutrition and athletic performance. Med Sci Sports Exerc 2009; 41:709–731. 12. Field AE, Flint A, Sonneville K, et al. Consumption of sports drinks prospectively associated with greater weight change among adolescents [Oral abstract 27-OR]. The Obesity Society 30th Annual Scientific Meeting; 21 September 2012; San Antonio, TX. 13. Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 2010; 121:1356–1364. 14. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health 2007; 97:667–675. 15. DeBoer MD, Scharf RJ, Demmer RT. Sugar-sweetened beverages and & weight gain in 2- to 5-year-old children. Pediatrics 2013; 132:413– 420. Using longitudinal data from a large nationally representative sample born in 2001, this study showed that regular consumption of SSBs at just 2 years of age was associated with greater weight gain by 4 years of age. 16. Pan A, Malik VS, Hao T, et al. Changes in water and beverage intake and long& term weight changes: results from three prospective cohort studies. Int J Obes (Lond) 2013; 37:1378–1385. This study evaluated the long-term relationships between changes in beverage consumption and body weight using data from three large prospective cohort studies with follow-up periods of 16–20 years. Analyses of data from nearly 125 000 men and women suggested a beneficial effect of replacing consumption of SSBs with water. 17. Mattes RD, Shikany JM, Kaiser KA, Allison DB. Nutritively sweetened beverage consumption and body weight: a systematic review and meta-analysis of randomized experiments. Obes Rev 2011; 12:346–365. 18. Maersk M, Belza A, Stodkilde-Jorgensen H, et al. Sucrose-sweetened bev& erages increase fat storage in the liver, muscle, and visceral fat depot: a 6-mo randomized intervention study. Am J Clin Nutr 2012; 95:283–289. This intervention study evaluated the effects of consuming SSBs, compared with three other beverages, over 6 months. Consumption of SSBs caused greater increases in liver fat, skeletal muscle fat and visceral fat, as measured using magnetic resonance techniques. 19. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004; 328:1237. 20. Ebbeling CB, Feldman HA, Osganian SK, et al. Effects of decreasing sugarsweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006; 117:673–680. 21. Tate DF, Turner-McGrievy G, Lyons E, et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr 2012; 95:555–563.
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22. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugarsweetened beverages and adolescent body weight. N Engl J Med 2012; 367:1407–1416. This randomized controlled trial provides convincing evidence that an intervention aimed at reducing consumption of SSBs attenuates the increase in BMI among adolescents. The intervention was multifaceted and included home deliveries of noncaloric beverages, educational check-in visits with adolescent participants and motivational telephone calls with parents. Evidence of effect modification by ethnic group suggested that Hispanics may be particularly susceptible to the adverse effects of consuming SSBs. 23. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar&& sweetened beverages and body weight in children. N Engl J Med 2012; 367:1397–1406. This is one of the most definitive randomized controlled trials conducted to date, particularly in light of the double-blind design. Schoolchildren who consumed a sugar-free beverage gained less weight over 18 months compared with those who consumed a SSB. The two beverages were formulated to be indistinguishable with regard to design and packaging, allowing careful comparison of the interventions independent of psychological or behavioural cues. 24. James J, Thomas P, Kerr D. Preventing childhood obesity: two year follow-up results from the Christchurch obesity prevention programme in schools (CHOPPS). BMJ 2007; 335:762. 25. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk of && obesity. N Engl J Med 2012; 367:1387–1396. This is the first study to show that consumption of SSBs can exacerbate genetic risk for obesity. Analyses utilized data from three large prospective cohort studies, comprising more than 33 000 participants, and a predisposition score based on 32 obesity genes. 26. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001; 357:505–508. 27. Goran MI, Bergman RN, Cruz ML, Watanabe R. Insulin resistance and associated compensatory responses in African-American and Hispanic children. Diabetes Care 2002; 25:2184–2190. 28. Haffner SM, D’Agostino R, Saad MF, et al. Increased insulin resistance and insulin secretion in nondiabetic African-Americans and Hispanics compared with non-Hispanic whites. The Insulin Resistance Atherosclerosis Study. Diabetes 1996; 45:742–748. 29. Haffner SM, Miettinen H, Stern MP. Nondiabetic Mexican-Americans do not have reduced insulin responses relative to nondiabetic non-Hispanic whites. Diabetes Care 1996; 19:67–69. 30. Taveras EM, Gillman MW, Kleinman KP, et al. Reducing racial/ethnic disparities in childhood obesity: the role of early life risk factors. JAMA Pediatr 2013; 167:731–738. 31. Ludwig DS. The glycemic index: physiological mechanisms relating to obesity, diabetes, and cardiovascular disease. JAMA 2002; 287:2414–2423. 32. Lustig RH, Schmidt LA, Brindis CD. Public health: the toxic truth about sugar. Nature 2012; 482:27–29. 33. Ludwig DS. Examining the health effects of fructose. JAMA 2013; 310:33–34. 34. Pan A, Hu FB. Effects of carbohydrates on satiety: differences between liquid and solid food. Curr Opin Clin Nutr Metab Care 2011; 14:385–390. 35. Sievenpiper JL, de Souza RJ, Mirrahimi A, et al. Effect of fructose on body weight in controlled feeding trials: a systematic review and meta-analysis. Ann Intern Med 2012; 156:291–304. 36. Howlett J, Ashwell M. Glycemic response and health: summary of a workshop. Am J Clin Nutr 2008; 87:212S–216S. 37. Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care 2010; 33:2477–2483. 38. Dhingra R, Sullivan L, Jacques PF, et al. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation 2007; 116:480–488. 39. de Koning L, Malik VS, Kellogg MD, et al. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation 2012; 125:1735–1741. 40. Fung TT, Malik V, Rexrode KM, et al. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr 2009; 89:1037–1042. 41. Ambrosini GL, Oddy WH, Huang RC, et al. Prospective associations between sugar-sweetened beverage intakes and cardiometabolic risk factors in adolescents. Am J Clin Nutr 2013; 98:327–334. 42. Duffey KJ, Gordon-Larsen P, Steffen LM, et al. Drinking caloric beverages increases the risk of adverse cardiometabolic outcomes in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Clin Nutr 2010; 92:954–959. 43. Abid A, Taha O, Nseir W, et al. Soft drink consumption is associated with fatty liver disease independent of metabolic syndrome. J Hepatol 2009; 51:918– 924. 44. Block JP, Gillman MW, Linakis SK, Goldman RE. ‘If it tastes good, I’m drinking & it’: qualitative study of beverage consumption among college students. J Adolesc Health 2013; 52:702–706. This focus group study provides interesting qualitative data, indicating that taste is a strong reason for consuming SSBs among young adults and that educational messages with shock appeal may be an important component of interventions to reduce consumption. &&
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Sugar-sweetened beverages and body weight Ebbeling 45. Zoellner J, Krzeski E, Harden S, et al. Qualitative application of the theory of planned behavior to understand beverage consumption behaviors among adults. J Acad Nutr Diet 2012; 112:1774–1784. 46. Pepino MY, Mennella JA. Factors contributing to individual differences in sucrose preference. Chem Senses 2005; 30 (Suppl 1):i319–i320. 47. Liem DG, de Graaf C. Sweet and sour preferences in young children and adults: role of repeated exposure. Physiol Behav 2004; 83:421–429. 48. Burger KS, Stice E. Neural responsivity during soft drink intake, anticipation, && and advertisement exposure in habitually consuming youth. Obesity (Silver Spring) 2013. [Epub ahead of print]. This study utilized state-of-the-art methodology (functional magnetic resonance imaging) to evaluate brain activity in response to consumption of a branded soft drink. Consumption activated taste and reward regions of the brain. Among regular consumers, seeing the brand logo activated a region of the brain thought to encode salience or attention to cues.
49. Sievenpiper JL, de Souza RJ. Are sugar-sweetened beverages the whole story? Am J Clin Nutr 2013; 98:261–263. 50. Colbert JA, Adler JN. Clinical decisions sugar-sweetened beverages: polling results. N Engl J Med 2013; 368:e4. 51. Mozaffarian D, Hao T, Rimm EB, et al. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011; 364:2392– 2404. 52. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009; 120:1011–1020. 53. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120 (Suppl 4):S164– S192.
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Sugar-sweetened beverages and body weight Cara B. Ebbeling
Purpose of review Given the high prevalence of obesity in the USA, much recent attention has focused on dietary strategies for weight control. Several medical and scientific societies currently recommend reducing consumption of sugar-sweetened beverages (SSBs). However, the evidence base for a public health recommendation has been a topic of debate. The purpose of this review is not to underscore the debate but rather to consider how recently published data pertaining to SSBs contribute to the evidence base for preventing and treating obesity, with application to caring for patients. Recent findings Consumption of SSBs remains prevalent in the USA. Emerging data from epidemiological studies and clinical trials indicate that consumption contributes to positive energy balance and reducing consumption has beneficial effects on body weight. Some individuals may be more susceptible to the adverse effects of consuming SSBs owing to their ethnicity or genetic predisposition. Plausible physiological mechanisms link consumption of SSBs with weight control. Summary Available data provide an evidence base for counselling patients to reduce consumption of SSBs. Nevertheless, additional research is needed to strengthen the evidence base, particularly studies aimed at understanding susceptibility to the adverse effects of consuming SSBs on body weight and mechanisms for these effects. Keywords BMI, dietary counselling, nutrition, obesity, sugar-sweetened beverages
INTRODUCTION Recently, much attention has been directed towards the evidence base for a recommendation to limit consumption of sugar-sweetened beverages (SSBs), as a dietary strategy for preventing and treating obesity. An evidence-based approach to establishing dietary guidelines or providing medical nutrition therapy relies on reviewing and evaluating available data; determining the strength of inference drawn from the data; and integrating data with nutrition expertise, sound judgement and perspectives of individuals for whom a recommendation may affect health [1]. Ongoing debate regarding a public health recommendation to limit consumption of SSBs stems largely from differences in opinion on evaluating and drawing inferences from available data [2,3]. The purpose of this review is not to underscore the debate but rather to consider how recently published data pertaining to SSBs contribute to the evidence base for preventing and treating obesity, with application to caring for patients. The following vignette provides a backdrop and context for highlighting some of the most important and interesting articles published between 1 January 2012
and 31 August 2013 that address a series of questions regarding SSBs.
VIGNETTE J.D. is a 14-year-old boy who weighs 105.1 kg and stands 173.5 cm tall. As such, his BMI is 34.9 kg/m2 and exceeds the 99th percentile for sex and age. He reports Hispanic ethnicity. Both of his parents are obese (BMI >30 kg/m2). His only sister has a BMI at the 49th percentile. J.D.’s fasting blood glucose is within normal limits (89 mg/dl), but his fasting insulin is elevated (68.3 mIU/ml). His blood lipid profile indicates total cholesterol (148 mg/dl) and LDL cholesterol (80 mg/dl) within normal limits but New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital, Boston, Massachusetts, USA Correspondence to Cara B. Ebbeling, PhD, New Balance Foundation Obesity Prevention Center, Boston Children’s Hospital, 300 Longwood Avenue (AU307), Boston, MA 02115, USA. Tel: +1 617 919 3457; fax: +1 617 730 0183; e-mail: [email protected] Curr Opin Lipidol 2014, 25:1–7 DOI:10.1097/MOL.0000000000000035
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KEY POINTS Consumption of SSBs is prevalent in the USA, with average consumption equating to approximately 150 kcal per day. Data from well conducted prospective observational studies indicate a significant relationship between consumption of SSBs and weight gain in children and adults. Two recent randomized controlled trials provide convincing evidence that reducing consumption of SSBs has beneficial effects on body weight. Ethnicity or genetics may influence susceptibility to the effects of consuming SSBs on body weight. Emerging data contribute to the evidence base for a recommendation to reduce consumption of SSBs, consistent with statements from several medical and academic societies.
low HDL cholesterol (32.8 mg/dl) and elevated triglycerides (173 mg/dl). His serum alanine aminotransferase (ALT) is slightly elevated (33 U/l). J.D. plays basketball three times per week in an afterschool league at a community centre. He reports a diet high in carbohydrate (mostly from refined sources), with adequate protein but minimal attention to vegetables and fruits. He also reports consuming a large glass of fruit punch for breakfast and his favourite brand of sports drinks when thirsty during basketball practice. All family members express the importance of health but are overwhelmed with changing their dietary habits.
WHAT ARE SUGAR-SWEETENED BEVERAGES? WHAT SUGAR-SWEETENED BEVERAGES CONTRIBUTE THE MOST TO ENERGY INTAKE? SSBs are termed ‘soft’ drinks, as opposed to alcoholic beverages that are considered ‘hard’ according to this jargon. Examples of SSBs include conventional carbonated beverages, or sodas, and noncarbonated beverages such as fruit drinks, enhanced waters, highly sweetened coffees and teas, sports drinks and energy drinks. These beverages typically are sweetened with high-fructose corn syrup (55% fructose and 45% glucose in monomeric form) or sucrose (50% fructose and 50% glucose in dimeric form) and provide between approximately 100 and 170 kcal per 12 fluid ounces. Sports drinks contain special formulations of electrolytes (sodium, potassium, calcium, magnesium), originally designed to replenish losses in sweat during intensive endurance 2
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events. Energy drinks are distinct from sports drinks and contain stimulants (most notably, large amounts of caffeine) and other ingredients alleged to enhance mental acuity and physical performance [4,5]. Data from the National Health and Nutrition Examination Survey (NHANES) indicate that the most prevalent sources of energy from SSBs are fruit drinks among children and sodas among adolescents and adults [6]. The contribution of fruit drinks and sodas to energy intake decreased modestly between 1999–2000 and 2007–2008 [6,7]. However, despite this decrease, average consumption of SSBs still equated to approximately 150 kcal per day in 2009–2010 [7], and the contribution of sports and energy drinks to energy intake increased among adolescents and adults over the last decade [6]. The relative contribution of sports vs. energy drinks to this increase is not well defined. Further discussion regarding the distinct adverse health effects of energy drinks [8,9] is beyond the scope of this review. Consuming sports drinks may be viewed as consistent with a healthful lifestyle, possibly due to advertising campaigns that feature famous athletes [10]. However, although athletes who are involved in intensive endurance events may benefit from sports drinks [11], choosing these products over water is unwarranted for most individuals engaged in routine or recreational physical activity. In a prospective cohort study (Growing Up Today Study II, 2004–2011) [12] of over 10 000 adolescents, intake of sports drinks was linked to greater increase in BMI (0.03 kg/m2 per serving per week, P ¼ 0.002), thereby contributing to weight gain much like other SSBs (discussed below).
DOES CONSUMPTION OF SUGARSWEETENED BEVERAGES CONTRIBUTE TO WEIGHT GAIN AND ADIPOSITY? The preponderance of epidemiological data from prospective cohort studies indicate a significant relationship between consumption of SSBs and weight gain, as summarized in previous reviews [2,13,14]. Recently published data contribute to the evidence base for this relationship in children and adults. DeBoer et al. [15 ] evaluated young children who were part of a nationally representative sample born in 2001 in the USA. They reported that those who drank SSBs regularly (at least one serving per day) at 2 years of age, compared with their counterparts who consumed less than one serving per day, gained more weight by 4 years of age as indicated by a greater increase in BMI z score over time (P < 0.05). At 5 years of age, habitual consumers had a higher odds of being obese (odds &
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ratio 1.43, P < 0.01) based on a cross-sectional analysis [15 ]. With regard to adults, Pan et al. [16 ] analysed pooled data from three large prospective cohort studies including the Nurses’ Health Study (NHS, 1986–2006), NHS II (1991–2007) and Health Professionals Follow-up Study (HPFS, 1986– 2006). Daily consumption of SSBs was associated with weight gain of 0.36 kg per serving over each 4-year period. Given that every one-cup increment of water consumed per day was associated with weight loss of 0.13 kg over each period, replacement of one serving of SSBs by one cup of water per day would be associated with 2.45 kg less weight gain over 20 years (0.49 kg per 4-year time period). The estimated substitution benefit was attributed to a decrease in total energy intake [16 ]. Results from short-term intervention studies are generally consistent with epidemiological data, suggesting that consumption of SSBs, compared with a control condition, contributes to weight gain. Although the magnitude and significance of weight gain differs across studies, a recently updated meta-analysis indicated a significant overall effect [3,17]. Concerning adiposity, Maersk et al. [18 ] reported that study participants who were instructed to drink 1 liter of sugar-sweetened cola per day had greater increases in liver, skeletal muscle and visceral fat than those who consumed the same volume of other beverages (milk, diet cola sweetened with aspartame or water) over 6 months, despite no differences for change in body weight or total fat mass. These findings suggest an increased risk for chronic diseases (discussed below) associated with regional adiposity. &
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WILL REDUCING CONSUMPTION OF SUGAR-SWEETENED BEVERAGES HAVE A BENEFICIAL EFFECT ON BODY WEIGHT? Data from randomized controlled trials on the effect of interventions aimed at reducing consumption of SSBs on body weight have emerged slowly over the last decade. Intervention effects include decreased rates of obesity among schoolchildren [19], decreased BMI among overweight or obese adolescents [20] and increased likelihood of substantial weight loss among adults [21]. However, in each of the cited studies, change in BMI or body weight was not significant among the full cohort of participants. Two recent and arguably more definitive randomized controlled trials contribute important data to the evidence base pertaining to the question at hand [22 ,23 ]. In both of these studies, participants regularly consumed SSBs prior to random assignment, and the primary aim was to evaluate the effect of reducing consumption on BMI. &&
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Ebbeling et al. [22 ] randomly assigned 224 overweight and obese adolescents to intervention and control groups for 2 years. Retention rates were 97% at 1 year and 93% at 2 years. Participants in the intervention group received home deliveries of noncaloric beverages, including water and artificially sweetened (’diet’) beverages, for 1 year. Reported consumption of SSBs dropped to almost nothing with the intervention. Significant between-group differences for changes in BMI (0.57, P ¼ 0.045) and body weight (1.9 kg, P ¼ 0.04) were observed over this time period, due to a smaller increase in BMI in the intervention group compared with the control group. After an additional 1-year follow-up period without home deliveries, changes in BMI (0.30; P ¼ 0.46) and body weight (0.8, P ¼ 0.55) did not differ between the two groups. This finding is consistent with a previous study showing that discontinuation of an intervention extinguishes group effects [24]. The data obtained at 1 year reflect the effects of an active intervention and arguably are more relevant in addressing the question at hand. de Ruyter et al. [23 ] randomly assigned 641 schoolchildren, aged 4–11 years, to receive one serving (250 ml) per day of a sugar-free beverage, sweetened with sucralose and acesulfame potassium, or a similar SSB containing 104 kcal. The completion rate was 74% at 18 months. The two beverages were formulated to be indistinguishable with regard to sweetness and packaging, and the trial was conducted according to a double-blind design. The group difference for a change in BMI z score was significant, given a smaller increase with consumption of the sugar-free beverage than with the SSB [0.02 vs. 0.15 units; 95% confidence interval (CI) of the difference, 0.21 to 0.05]. Likewise, weight increased less with consumption of the sugar-free beverage compared with the SSB (6.35 vs. 7.37 kg; 95% CI for the difference, 1.54 to 0.48). Fat mass also increased less in the group consuming the sugar-free beverage. &&
ARE SOME INDIVIDUALS PARTICULARLY SUSCEPTIBLE TO THE EFFECT OF CONSUMING SUGAR-SWEETENED BEVERAGES ON BODY WEIGHT? &&
Data from recent studies suggest that ethnicity [22 ] or genetics [25 ] may influence susceptibility. Evidence of effect modification by ethnic group was noted in the aforementioned study by Ebbeling et al. [22 ]. Among Hispanic participants, the difference in BMI between the intervention and control groups was significant following 1 year of home deliveries of noncaloric beverages (1.79, P ¼ 0.007) and after an additional 1-year follow-up period (2.35, P ¼ 0.01). The group effect was not
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significant among non-Hispanic participants. Reanalysis of data from a 19-month prospective observational study of 548 middle-school students [26] also showed effect modification by ethnic group (P ¼ 0.007), with a strong association between change in consumption of SSBs and change in BMI for the Hispanics but no association for the non-Hispanics [22 ]. The reason for effect modification by ethnic group remains hypothetical and may involve differences in insulin secretion following sugar consumption [27–29], genetic susceptibility [25 ] and other factors influencing disparities in BMI such as socioeconomic status and early feeding behaviours [30]. Qi et al. [25 ] recently reported that frequent consumption of SSBs modified the genetic risk of obesity in three large cohorts of individuals from European ancestry. Researchers quantified genetic risk using a predisposition score based on 32 singlenucleotide polymorphisms, with each point of the score corresponding to one risk allele. On the basis of data from the NHS (18 years of follow-up) and HPFS (12 years of follow-up), the relative risk of incident obesity for each increment of 10 risk alleles was 5.06 (95% CI, 1.66–15.5) for consumption of one or more servings of SSBs per day, compared with 1.19 (95% CI, 0.90–1.59) for consumption of less than one serving per month. Findings from an independent large cohort of women (Women’s Genome Health Study, 6 years of follow-up) were similar [25 ]. These data suggest that consumption of SSBs may exacerbate weight gain among genetically susceptible individuals, and reducing consumption may attenuate genetic predisposition. However, whether these findings are generalizable to other ethnic-racial groups requires additional research. &&
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WHAT ARE THE MECHANISMS BY WHICH SUGAR-SWEETENED BEVERAGES MAY EXERT AN ADVERSE EFFECT ON BODY WEIGHT? Plausible mechanisms involve postprandial hyperglycemia, rapid absorption of fructose and lessened satiety. When SSBs are consumed in large amounts, particularly without other foods containing protein and fat to attenuate the carbohydrate-induced rise in blood glucose, rapid absorption of glucose has the potential to cause postprandial hyperglycemia that initiates a cascade of events. These include an increase in circulating insulin relative to glucagon, glucose uptake by insulin-sensitive tissues, a subsequent drop in blood glucose to concentrations below fasting levels, increased hunger due to limited fuel availability and overeating [31]. In contrast to 4
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glucose, fructose is metabolized primarily in the liver. Rapid absorption of fructose from SSBs may overwhelm hepatic metabolic pathways, fuel denovo lipogenesis and cause physiological aberrations such as excess fat deposition and insulin resistance [32,33]. With regard to lessened satiety, consumption of energy in liquid vs. solid form may lead to incomplete compensatory reductions in energy intake from other sources and thereby positive energy balance [34]. However, the strength of evidence for each of these mechanisms remains open to debate [3,35,36].
DOES CONSUMPTION OF SUGARSWEETENED BEVERAGES AFFECT RISK FOR OBESITY-RELATED CHRONIC DISEASES? Although not the primary focus of this review, the link between consumption of SSBs and risk for obesity-related chronic diseases is an important consideration when building context for dietary counselling. Findings from prospective cohort studies indicate significant associations between consumption of SSBs and incidence of metabolic syndrome [37,38], type 2 diabetes [37] and coronary heart disease [39,40]. Moreover, consumption has been associated, either in longitudinal or cross-sectional analyses, with individual components and clinical manifestations of the metabolic syndrome. These include increased waist circumference [38,41], impaired fasting glucose [38], increased blood levels of triglycerides [38,39,41,42], decreased levels of HDL cholesterol [38,39,41], elevated blood pressure [38,42], increased levels of biomarkers for chronic inflammation [39] and indicators of nonalcoholic fatty liver disease including ALT [43]. Controlling for body weight attenuates without fully extinguishing some of these associations [37,40,41], suggesting weight-dependent and weight-independent pathways linking consumption of SSBs with chronic diseases.
REVISITING THE VIGNETTE Drawing inference from the evidence base, a recommendation to reduce consumption of SSBs, is appropriate for patients such as J.D. who are overweight or obese. Hispanic ethnicity, family history of obesity and a profile of laboratory values consistent with metabolic aberrations linked with consumption of SSBs provide additional context for the recommendation. Nevertheless, several questions, in addition to those posed above, are likely to surface when negotiating plans to reduce consumption of SSBs. Volume 25 Number 1 February 2014
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Why do patients consume sugar-sweetened beverages? There are many reasons, with taste being foremost [44 ,45]. Branding may influence taste preferences and beverage choices for patients such as J.D. [44 ]. Strong preferences for the tastes of favourite brands likely develop through habitual consumption [46,47], leading to excessive stimulation of taste receptors on the tongue that cause a rewarding sensation. Consistent with this line of reasoning, a neuroimaging study conducted by Burger and Stice [48 ] indicated activation of taste and reward regions of the brain in response to consumption of a branded soft drink. Among habitual consumers, the brand logo elicited a response in a region of the brain thought to encode salience or attention to cues [48 ]. &
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What type of education would prompt patients to recognize a need for reducing consumption of sugar-sweetened beverages? Adolescents and young adults often dismiss the adverse effects of consumption on their personal health [44 ]. Education concerning these effects likely is an important component of an intervention for patients such as J.D. During focus groups conducted by Block et al. [44 ], young adults suggested that health messages with shock appeal and graphical representation of information would get their attention. Under the theme of Think Before You Drink, Ebbeling et al. [22 ] provided an interactive educational programme that covered topics such as sugar content of popular beverages; importance of drinking unsweetened water for hydration; possible effects of SSBs in promoting excess energy intake, weight gain, tooth decay, hunger and lethargy; and caution with regard to misleading beverage labels and advertisements. &
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patients such as J.D. Although parents may express concern over depriving normal weight siblings of their favourite SSBs, such concern can be addressed with evidence that avoiding SSBs prevents excessive weight gain over the long term among individuals who are not overweight or obese [16 ]. &
Is a focus on sugar-sweetened beverages too narrow when counselling patients around weight control? Of course, SSBs are not the only sources of refined carbohydrate, and many dietary behaviours contribute to obesity [49,50]. Nevertheless, for patients such as J.D. who are overwhelmed when attempting to change dietary behaviours, a recommendation to reduce consumption of SSBs is a reasonable first step in light of the evidence base documenting measureable and beneficial effects of reduced consumption on body weight. Such a recommendation is arguably less confusing than other dietary intervention messages, especially in that an ideal replacement for SSBs is simply unsweetened water. Over time and depending on patient readiness, a practitioner can expand the focus of nutrition education and dietary counselling to recommend increased consumption of healthful foods (vegetables, whole grains, fruits) and reduced consumption of foods that, along with SSBs, are components of unhealthful dietary patterns [51].
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What support do patients need from other people to reduce consumption of sugar-sweetened beverages? In addition to strong taste preferences, ready availability of SSBs at home and the influence of parents or peers who purchase and consume SSBs are potentially important determinants of consumption [10,45]. Provision of noncaloric beverages, education (discussed above) and respectful counselling on strategies for overcoming environmental and social factors that facilitate consumption of SSBs are effective strategies when used in combination for promoting reduced consumption [20,22 ]. Removing SSBs from the home, providing noncaloric beverages (including safe tap water) [10] and modelling consumption of noncaloric beverages are arguably among the most important types of support that family members can provide for &&
CONCLUSION Current debate need not detract from a recommendation to reduce consumption of SSBs. Indeed, statements from several medical and academic societies encourage reduced consumption for controlling body weight and risk for obesity-related chronic diseases [52,53]. Findings presented in recent articles provide support for these statements and contribute to the expanding evidence base for a recommendation to reduce consumption of SSBs in efforts aimed at obesity prevention and treatment. Additional research is needed to strengthen the evidence base, particularly studies aimed at understanding susceptibility to the adverse effects of consuming SSBs on body weight and mechanisms for these effects. Acknowledgements Dr Ebbeling has received funding from the National Institutes of Health to study the effect of consuming SSBs on body weight. Conflicts of interest There are no conflicts of interest.
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REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Montori VM, Guyatt GH. Progress in evidence-based medicine. JAMA 2008; 300:1814–1816. 2. Hu FB. Resolved: there is sufficient scientific evidence that decreasing sugarsweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013; 14:606–619. 3. Kaiser KA, Shikany JM, Keating KD, Allison DB. Will reducing sugar-sweetened beverage consumption reduce obesity? Evidence supporting conjecture is strong, but evidence when testing effect is weak. Obes Rev 2013; 14:620–633. 4. Campbell B, Wilborn C, La Bounty P, et al. International Society of Sports Nutrition position stand: energy drinks. J Int Soc Sports Nutr 2013; 10:1. 5. Committee on Nutrition and the Council on Sports Medicine and Fitness. Sports drinks and energy drinks for children and adolescents: are they appropriate? Pediatrics 2011; 127:1182–1189. 6. Han E, Powell LM. Consumption patterns of sugar-sweetened beverages in the United States. J Acad Nutr Diet 2013; 113:43–53. 7. Kit BK, Fakhouri TH, Park S, et al. Trends in sugar-sweetened beverage consumption among youth and adults in the United States. Am J Clin Nutr 2013; 98:180–188. 8. Seifert SM, Schaechter JL, Hershorin ER, Lipshultz SE. Health effects of energy drinks on children, adolescents, and young adults. Pediatrics 2011; 127:511–528. 9. Jackson DA, Cotter BV, Merchant RC, et al. Behavioral and physiologic adverse effects in adolescent and young adult emergency department patients reporting use of energy drinks and caffeine. Clin Toxicol (Phila) 2013; 51:557–565. 10. Bogart LM, Cowgill BO, Sharma AJ, et al. Parental and home environmental facilitators of sugar-sweetened beverage consumption among overweight and obese latino youth. Acad Pediatr 2013; 13:348–355. 11. Rodriguez NR, Di Marco NM, Langley S. American College of Sports Medicine position stand. Nutrition and athletic performance. Med Sci Sports Exerc 2009; 41:709–731. 12. Field AE, Flint A, Sonneville K, et al. Consumption of sports drinks prospectively associated with greater weight change among adolescents [Oral abstract 27-OR]. The Obesity Society 30th Annual Scientific Meeting; 21 September 2012; San Antonio, TX. 13. Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 2010; 121:1356–1364. 14. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health 2007; 97:667–675. 15. DeBoer MD, Scharf RJ, Demmer RT. Sugar-sweetened beverages and & weight gain in 2- to 5-year-old children. Pediatrics 2013; 132:413– 420. Using longitudinal data from a large nationally representative sample born in 2001, this study showed that regular consumption of SSBs at just 2 years of age was associated with greater weight gain by 4 years of age. 16. Pan A, Malik VS, Hao T, et al. Changes in water and beverage intake and long& term weight changes: results from three prospective cohort studies. Int J Obes (Lond) 2013; 37:1378–1385. This study evaluated the long-term relationships between changes in beverage consumption and body weight using data from three large prospective cohort studies with follow-up periods of 16–20 years. Analyses of data from nearly 125 000 men and women suggested a beneficial effect of replacing consumption of SSBs with water. 17. Mattes RD, Shikany JM, Kaiser KA, Allison DB. Nutritively sweetened beverage consumption and body weight: a systematic review and meta-analysis of randomized experiments. Obes Rev 2011; 12:346–365. 18. Maersk M, Belza A, Stodkilde-Jorgensen H, et al. Sucrose-sweetened bev& erages increase fat storage in the liver, muscle, and visceral fat depot: a 6-mo randomized intervention study. Am J Clin Nutr 2012; 95:283–289. This intervention study evaluated the effects of consuming SSBs, compared with three other beverages, over 6 months. Consumption of SSBs caused greater increases in liver fat, skeletal muscle fat and visceral fat, as measured using magnetic resonance techniques. 19. James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004; 328:1237. 20. Ebbeling CB, Feldman HA, Osganian SK, et al. Effects of decreasing sugarsweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006; 117:673–680. 21. Tate DF, Turner-McGrievy G, Lyons E, et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr 2012; 95:555–563.
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22. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugarsweetened beverages and adolescent body weight. N Engl J Med 2012; 367:1407–1416. This randomized controlled trial provides convincing evidence that an intervention aimed at reducing consumption of SSBs attenuates the increase in BMI among adolescents. The intervention was multifaceted and included home deliveries of noncaloric beverages, educational check-in visits with adolescent participants and motivational telephone calls with parents. Evidence of effect modification by ethnic group suggested that Hispanics may be particularly susceptible to the adverse effects of consuming SSBs. 23. de Ruyter JC, Olthof MR, Seidell JC, Katan MB. A trial of sugar-free or sugar&& sweetened beverages and body weight in children. N Engl J Med 2012; 367:1397–1406. This is one of the most definitive randomized controlled trials conducted to date, particularly in light of the double-blind design. Schoolchildren who consumed a sugar-free beverage gained less weight over 18 months compared with those who consumed a SSB. The two beverages were formulated to be indistinguishable with regard to design and packaging, allowing careful comparison of the interventions independent of psychological or behavioural cues. 24. James J, Thomas P, Kerr D. Preventing childhood obesity: two year follow-up results from the Christchurch obesity prevention programme in schools (CHOPPS). BMJ 2007; 335:762. 25. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk of && obesity. N Engl J Med 2012; 367:1387–1396. This is the first study to show that consumption of SSBs can exacerbate genetic risk for obesity. Analyses utilized data from three large prospective cohort studies, comprising more than 33 000 participants, and a predisposition score based on 32 obesity genes. 26. Ludwig DS, Peterson KE, Gortmaker SL. 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Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation 2007; 116:480–488. 39. de Koning L, Malik VS, Kellogg MD, et al. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation 2012; 125:1735–1741. 40. Fung TT, Malik V, Rexrode KM, et al. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr 2009; 89:1037–1042. 41. Ambrosini GL, Oddy WH, Huang RC, et al. Prospective associations between sugar-sweetened beverage intakes and cardiometabolic risk factors in adolescents. Am J Clin Nutr 2013; 98:327–334. 42. Duffey KJ, Gordon-Larsen P, Steffen LM, et al. Drinking caloric beverages increases the risk of adverse cardiometabolic outcomes in the Coronary Artery Risk Development in Young Adults (CARDIA) Study. Am J Clin Nutr 2010; 92:954–959. 43. Abid A, Taha O, Nseir W, et al. Soft drink consumption is associated with fatty liver disease independent of metabolic syndrome. J Hepatol 2009; 51:918– 924. 44. Block JP, Gillman MW, Linakis SK, Goldman RE. ‘If it tastes good, I’m drinking & it’: qualitative study of beverage consumption among college students. J Adolesc Health 2013; 52:702–706. This focus group study provides interesting qualitative data, indicating that taste is a strong reason for consuming SSBs among young adults and that educational messages with shock appeal may be an important component of interventions to reduce consumption. &&
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Sugar-sweetened beverages and body weight Ebbeling 45. Zoellner J, Krzeski E, Harden S, et al. Qualitative application of the theory of planned behavior to understand beverage consumption behaviors among adults. J Acad Nutr Diet 2012; 112:1774–1784. 46. Pepino MY, Mennella JA. Factors contributing to individual differences in sucrose preference. Chem Senses 2005; 30 (Suppl 1):i319–i320. 47. Liem DG, de Graaf C. Sweet and sour preferences in young children and adults: role of repeated exposure. Physiol Behav 2004; 83:421–429. 48. Burger KS, Stice E. Neural responsivity during soft drink intake, anticipation, && and advertisement exposure in habitually consuming youth. Obesity (Silver Spring) 2013. [Epub ahead of print]. This study utilized state-of-the-art methodology (functional magnetic resonance imaging) to evaluate brain activity in response to consumption of a branded soft drink. Consumption activated taste and reward regions of the brain. Among regular consumers, seeing the brand logo activated a region of the brain thought to encode salience or attention to cues.
49. Sievenpiper JL, de Souza RJ. Are sugar-sweetened beverages the whole story? Am J Clin Nutr 2013; 98:261–263. 50. Colbert JA, Adler JN. Clinical decisions sugar-sweetened beverages: polling results. N Engl J Med 2013; 368:e4. 51. Mozaffarian D, Hao T, Rimm EB, et al. Changes in diet and lifestyle and long-term weight gain in women and men. N Engl J Med 2011; 364:2392– 2404. 52. Johnson RK, Appel LJ, Brands M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009; 120:1011–1020. 53. Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120 (Suppl 4):S164– S192.
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