Jean A. Welsh

Consumption of added sugars is decreasing in the United States

BACKGROUND The consumption of added sugars (caloric sweeteners) has been linked to obesity, diabetes, and heart disease. Little is known about recent consumption trends in the United States or how intakes compare with current guidelines. OBJECTIVE We examined trends in intakes of added sugars in the United States over the past decade. DESIGN A cross-sectional study of US residents ≥2 y of age (n = 42,316) was conducted by using dietary data from NHANES 1999-2008 (five 2-y cycles) and data for added-sugar contents from the MyPyramid Equivalents Database. Mean intakes of added sugars (grams and percentage of total energy intake) were weighted to obtain national estimates over time across age, sex, and race-ethnic groups. Linear trends were tested by using Walds F tests. RESULTS Between 1999-2000 and 2007-2008, the absolute intake of added sugars decreased from a mean (95% CI) of 100.1 g/d (92.8, 107.3 g/d) to 76.7 g/d (71.6, 81.9 g/d); two-thirds of this decrease, from 37.4 g/d (32.6, 42.1 g/d) to 22.8 g/d (18.4, 27.3 g/d), resulted from decreased soda consumption (P-linear trend <0.001 for both). Energy drinks were the only source of added sugars to increase over the study period (P-linear trend = 0.003), although the peak consumption reached only 0.15 g/d (0.08, 0.22 g/d). The percentage of total energy from added sugars also decreased from 18.1% (16.9%, 19.3%) to 14.6% (13.7%, 15.5%) (P-linear trend <0.001). CONCLUSION Although the consumption of added sugars in the United States decreased between 1999-2000 and 2007-2008, primarily because of a reduction in soda consumption, mean intakes continue to exceed recommended limits.

Caloric Sweetener Consumption and Dyslipidemia Among US Adults

CONTEXT Dietary carbohydrates have been associated with dyslipidemia, a lipid profile known to increase cardiovascular disease risk. Added sugars (caloric sweeteners used as ingredients in processed or prepared foods) are an increasing and potentially modifiable component in the US diet. No known studies have examined the association between the consumption of added sugars and lipid measures. OBJECTIVE To assess the association between consumption of added sugars and blood lipid levels in US adults. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study among US adults (n = 6113) from the National Health and Nutrition Examination Survey (NHANES) 1999-2006. Respondents were grouped by intake of added sugars using limits specified in dietary recommendations (< 5% [reference group], 5%-<10%, 10%-<17.5%, 17.5%-<25%, and > or = 25% of total calories). Linear regression was used to estimate adjusted mean lipid levels. Logistic regression was used to determine adjusted odds ratios of dyslipidemia. Interactions between added sugars and sex were evaluated. MAIN OUTCOME MEASURES Adjusted mean high-density lipoprotein cholesterol (HDL-C), geometric mean triglycerides, and mean low-density lipoprotein cholesterol (LDL-C) levels and adjusted odds ratios of dyslipidemia, including low HDL-C levels (< 40 mg/dL for men; < 50 mg/dL for women), high triglyceride levels (> or = 150 mg/dL), high LDL-C levels (> or = 130 mg/dL), or high ratio of triglycerides to HDL-C (> 3.8). Results were weighted to be representative of the US population. RESULTS A mean of 15.8% of consumed calories was from added sugars. Among participants consuming less than 5%, 5% to less than 17.5%, 17.5% to less than 25%, and 25% or greater of total energy as added sugars, adjusted mean HDL-C levels were, respectively, 58.7, 57.5, 53.7, 51.0, and 47.7 mg/dL (P < .001 for linear trend), geometric mean triglyceride levels were 105, 102, 111, 113, and 114 mg/dL (P < .001 for linear trend), and LDL-C levels modified by sex were 116, 115, 118, 121, and 123 mg/dL among women (P = .047 for linear trend). There were no significant trends in LDL-C levels among men. Among higher consumers (> or = 10% added sugars) the odds of low HDL-C levels were 50% to more than 300% greater compared with the reference group (< 5% added sugars). CONCLUSION In this study, there was a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.

Consumption of Added Sugars and Indicators of Cardiovascular Disease Risk Among US Adolescents

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality among U.S. adults.1 While atherosclerosis and CVD occur later in life, their risk factors, including lipid disorders2, diabetes3, and obesity are increasingly being identified among adolescents and even children.4 Though CVD among children is rare,4 an increase in cardiometabolic risk factors at younger ages and their apparent tendency to track into adulthood5–7 highlights the need for early and effective prevention efforts. Lifestyle changes, including dietary change, have long been a central focus of efforts to reduce CVD risk. Since the 1950’s Americans have been advised to reduce their consumption of fats and cholesterol, and replace them with complex carbohydrates.8 It appears that, in part, Americans have followed this advice. But while food disappearance data suggests that fat consumption has decreased, it is refined rather than complex carbohydrates that have increased.9 While the overall health impact of this trend is unclear, several studies have shown a positive correlation between the consumption of carbohydrates – particularly some sugars - and the presence of CVD risk factors.10–12 A recent longitudinal study among women demonstrated that the incidence of CVD increased with higher consumption of sugar-sweetened beverages,13 the largest contributor of added sugars in the U.S. diet.14 Studies comparing the impact of different sugars have demonstrated that the monosaccharide fructose but not glucose, raises triglyceride levels and lowers HDL levels, suggesting that the metabolic impact may differ substantially by sugar type.12, 15 Added sugars are refined, calorie-containing sweeteners added to foods and beverages during processing or preparation. Consumption of these sugars has increased substantially in recent decades. Sugars used to sweeten soft drinks have become the largest single source of calories in the U.S. diet.16 In 1994–1996, Americans over the age of 2 y obtained nearly 16% of their total energy from added sugars; adolescents, the highest consumers, obtained more than 20% of their energy from sugars added to foods and beverages.17 Today in the U.S., the most commonly consumed added sugars are refined beet or cane sugar (sucrose) and high fructose corn syrup (HFCS),18 both of which contribute fructose and glucose, in approximately equal amounts, to the diet. Added sugars are estimated to contribute 74%–80% of the dietary fructose consumed.19, 20 Given the high consumption of added sugars among adolescents and the potential for long-term health risks associated with early diet, it is important to understand the impact of this dietary trend. The purpose of our study was to determine if there is an association between the consumption of added sugars and indicators of cardiometabolic health among U.S. adolescents.Background— Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. Methods and Results— In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated by added sugar consumption level (<10%, 10 to <15%, 15 to <20%, 20 to <25%, 25 to <30%, and ≥30% of total energy). Multivariable means were weighted to be representative of US adolescents and variances adjusted for the complex sampling methods. Daily consumption of added sugars averaged 21.4% of total energy. Added sugars intake was inversely correlated with mean high-density lipoprotein cholesterol levels (mmol/L) which were 1.40 (95% confidence interval [CI] 1.36 to 1.44) among the lowest consumers and 1.28 (95% CI 1.23 to 1.33) among the highest (P trend =0.001). Added sugars were positively correlated with low-density lipoproteins (P trend =0.01) and geometric mean triglycerides (P trend =0.05). Among the lowest and highest consumers, respectively, low-density lipoproteins (mmol/L) were 2.24 (95% CI 2.12 to 2.37) and 2.44 (95% CI 2.34 to 2.53), and triglycerides (mmol/L) were 0.81 (95% CI 0.74, 0.88) and 0.89 (95% CI 0.83 to 0.96). Among those overweight/obese (≥85th percentile body-mass-index), added sugars were positively correlated with the homeostasis model assessment (P linear trend =0.004). Conclusion— Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.

Childhood Obesity: Update on Predisposing Factors and Prevention Strategies

Obesity is a global epidemic and children are affected in increasing numbers. Overweight children are at increased risk of becoming overweight adults with associated chronic diseases. In this update, we present key findings from a review of the current literature focused on potential causes and strategies for preventing childhood obesity. We highlight recent evidence regarding the role of genetics, maternal body mass index, postnatal influences, and environmental effects throughout childhood in predicting overweight. We also summarize the results of new research that examined the effectiveness of intervention strategies implemented in a variety of settings: home, school, community, and health care system. Statements recently released by the Centers for Disease Control and Prevention (CDC) and the US Department of Health and Human Services emphasize the need for effective policy and environmental change to promote healthy lifestyle change at the individual and population levels.

Low-calorie sweetener consumption is increasing in the United States

BACKGROUND Low-calorie and no-calorie sweeteners (LCSs) have emerged as alternatives to added sugars. Research suggests that consumption among all Americans is increasing, yet it is unknown whether consumption trends differ among population subgroups. OBJECTIVE Our study aimed to assess recent national trends in LCS consumption among children and other demographic subgroups in the United States. DESIGN We used NHANES data collected in five 2-y cycles from 1999-2000 to 2007-2008. Consumption of foods and beverages with LCSs was estimated by using one 24-h dietary recall. Estimates of the proportion of the population consuming foods and beverages containing LCSs (prevalence of consumption) were weighted to obtain nationally representative results. Trends in prevalence of LCS consumption and mean intake of beverages sweetened with LCSs were tested by using chi-square tests for trend and F tests. RESULTS In 2007-2008, the percentage of children and adults consuming foods and beverages containing LCSs increased. The prevalence of consuming beverages with LCSs increased from 6.1% to 12.5% among children (P-trend < 0.0001) and from 18.7% to 24.1% among adults (P < 0.001). Increases in the prevalence of consumption of calorie-containing beverages with LCSs were observed among all weight, age, socioeconomic, and race-ethnicity subgroups in both children and adults. However, little change in consumption of no-calorie beverages with LCSs or LCS-containing foods was found. CONCLUSIONS The consumption of LCS-containing beverages has doubled among US children over the past decade. Further research is needed to understand the health effects of this trend.

Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association.

Background: Poor lifestyle behaviors are leading causes of preventable diseases globally. Added sugars contribute to a diet that is energy dense but nutrient poor and increase risk of developing obesity, cardiovascular disease, hypertension, obesity-related cancers, and dental caries. Methods and Results: For this American Heart Association scientific statement, the writing group reviewed and graded the current scientific evidence for studies examining the cardiovascular health effects of added sugars on children. The available literature was subdivided into 5 broad subareas: effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity. Conclusions: Associations between added sugars and increased cardiovascular disease risk factors among US children are present at levels far below current consumption levels. Strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia. The committee found that it is reasonable to recommend that children consume ⩽25 g (100 cal or ≈6 teaspoons) of added sugars per day and to avoid added sugars for children <2 years of age. Although added sugars most likely can be safely consumed in low amounts as part of a healthy diet, few children achieve such levels, making this an important public health target.

Children with NAFLD Are More Sensitive to the Adverse Metabolic Effects of Fructose Beverages than Children without NAFLD

CONTEXT Dietary fructose induces unfavorable lipid alterations in animal models and adult studies. Little is known regarding metabolic tolerance of dietary fructose in children. OBJECTIVES The aim of the study was to evaluate whether dietary fructose alters plasma lipids in children with nonalcoholic fatty liver disease (NAFLD) and in healthy children. DESIGN AND SETTING We performed a 2-d, crossover feeding study at the Inpatient Clinical Interaction Site of the Atlanta Clinical and Translational Science Institute at Emory University Hospital. PARTICIPANTS AND INTERVENTION Nine children with NAFLD and 10 matched controls without NAFLD completed the study. We assessed plasma lipid levels over two nonconsecutive, randomly assigned, 24-h periods under isocaloric, isonitrogenous conditions with three macronutrient-balanced, consecutive meals and either: 1) a fructose-sweetened beverage (FB); or 2) a glucose beverage (GB) being consumed with each meal. MAIN OUTCOME MEASURES Differences in plasma glucose, insulin, triglyceride, apolipoprotein B, high-density lipoprotein cholesterol, and nonesterified free fatty acid levels were assessed using mixed models and 24-h incremental areas under the time-concentration curve. RESULTS After FB, triglyceride incremental area under the curve was higher vs. after GB both in children with NAFLD (P = 0.011) and those without NAFLD (P = 0.027); however, incremental response to FB was greater in children with NAFLD than those without NAFLD (P = 0.019). For all subjects, high-density lipoprotein cholesterol declined in the postprandial and overnight hours with FB, but not with GB (P = 0.0006). Nonesterified fatty acids were not impacted by sugar but were significantly higher in NAFLD. CONCLUSIONS The dyslipidemic effect of dietary fructose occurred in both healthy children and those with NAFLD; however, children with NAFLD demonstrated increased sensitivity to the impact of dietary fructose.

Dietary Fructose Reduction Improves Markers of Cardiovascular Disease Risk in Hispanic-American Adolescents with NAFLD

Nonalcoholic fatty liver disease (NAFLD) is now thought to be the most common liver disease worldwide. Cardiovascular complications are a leading cause of mortality in NAFLD. Fructose, a common nutrient in the westernized diet, has been reported to be associated with increased cardiovascular risk, but its impact on adolescents with NAFLD is not well understood. We designed a 4-week randomized, controlled, double-blinded beverage intervention study. Twenty-four overweight Hispanic-American adolescents who had hepatic fat >8% on imaging and who were regular consumers of sweet beverages were enrolled and randomized to calorie-matched study-provided fructose only or glucose only beverages. After 4 weeks, there was no significant change in hepatic fat or body weight in either group. In the glucose beverage group there was significantly improved adipose insulin sensitivity, high sensitivity C-reactive protein (hs-CRP), and low-density lipoprotein (LDL) oxidation. These findings demonstrate that reduction of fructose improves several important factors related to cardiovascular disease despite a lack of measurable improvement in hepatic steatosis. Reducing dietary fructose may be an effective intervention to blunt atherosclerosis progression among NAFLD patients and should be evaluated in longer term clinical trials.

Changing Beverage Consumption Patterns Have Resulted in Fewer Liquid Calories in the Diets of US Children: National Health and Nutrition Examination Survey 2001-2010

BACKGROUND Beverage consumption patterns have been linked to obesity and chronic disease risk. Although the consumption of sugar-sweetened beverages (SSBs) has decreased recently, little is known about the parallel trends in intake of other beverages. OBJECTIVE To describe recent trends in consumption of all commonly consumed beverages among US children aged 2 to 19 years. DESIGN Twenty-four-hour dietary recalls from 18,541 participants in the National Health and Nutrition Examination Survey from 2001-2010 were used to assess beverage intake, including SSBs (ie, sodas, fruit-flavored drinks, sport and energy drinks, fruit juices, coffees/teas, and other [nondairy] sugar-sweetened drinks); milks (ie, plain whole, reduced fat, and low-/nonfat, sweetened, other milks/milk-based drinks, and milk alternatives); 100% juices (ie, fruit, and vegetable/mixed without added sugar); low-/no-calorie beverages (ie, unsweetened or artificially sweetened: sodas, coffees/teas, flavored waters, diet sport/energy drinks, and other low/no-calorie drinks); alcohol-containing; and plain water (during 2005-2010 only). Weighted mean intakes (percent total energy and total ounces) and consumption prevalence were estimated. Regression models and analytical procedures that account for the complex sampling methods were used to test trends. RESULTS Between 2001-2002 and 2009-2010, total daily beverage consumption (excluding water) decreased from 24.4% to 21.1% energy (32.0 to 27.9 oz). Significant decreases (P<0.05) occurred in sugar-sweetened sodas (13.5% to 10.2% energy), whole milk (2.7% to 1.6% energy), fruit juices with sugar added (2.3% to 2.1% energy), and fruit-flavored drinks (1.6% to 0.8% energy). Significant increases occurred for sweetened coffees/teas, energy drinks, sport drinks, and unsweetened juices though the contribution of each to total energy intake remained <1%. Low-/no-calorie drink consumption also increased, rising from 0.2 to 1.3 oz/day. CONCLUSIONS Changing beverage consumption patterns reflect positive trends in the form of reduced intake of SSBs, whole milk, and total calories from beverages. Although the consumption of sport drinks, energy drinks, and low-calorie beverages have increased, their contribution to total beverage intake remains small.

Fructose and Oxidized Low-Density Lipoprotein in Pediatric Nonalcoholic Fatty Liver Disease: A Pilot Study

Diet changes are a primary lifestyle change recommended in the treatment of pediatric nonalcoholic fatty liver disease (NAFLD), however, it is not clear which diet components are the most important to target. In the U.S., the consumption of fructose has increased nearly 50% and, on average, adolescents have a high intake (12% of total daily calories).1 Diets high in fructose are known to increase plasma lipids and oxidative stress2, both areas suspected in NAFLD pathogenesis. Recently, NAFLD patients were found to consume more fructose compared to matched controls.3 Given this and our previous animal studies4, we designed a pilot study evaluating a low-fructose diet in children with nonalcoholic fatty liver disease.