Is the increment of diabetes mellitus in Brazil associated with the consumption of artificially sweetened beverages? A time trend analysis with 757,386 adults from 2006 to 2020.

OBJECTIVE: To describe trends in the prevalence of diabetes mellitus (DM) in Brazil and to analyze its association with the consumption of artificially sweetened beverages among individuals aged 18 years or older. STUDY DESIGN: This was a repeated cross-sectional study. METHODS: Annual data from VIGITEL surveys (2006-2020) were used, which included adults from all Brazilian state capitals. The outcome was the prevalence of DM (type 1 and type 2). The main exposure variable was consuming beverages like soft drinks and artificial juices, either in its 'diet, light, or zero' form. Covariates included sex, age, sociodemographic characteristics, smoking, alcohol consumption, physical activity, fruit consumption, and obesity. The temporal trend in the indicators and the etiological fraction (population attributable risk [PAR]) were calculated. Analyses were performed using Poisson regression. The association between DM and consumption of beverages was tested, excluding the year 2020 due to the pandemic; restricting the analysis to the final three years (2018-2020). RESULTS: Overall, 757,386 subjects were included. The prevalence of DM increased from 5.5% to 8.2%, with an annual growth of 0.17 percentage points (95% CI 0.11-0.24). Among those who consumed diet/light/zero beverages, the annual percentage change of DM was four times greater. The PAR corresponding to the consumption of diet/light/zero beverages on the occurrence of DM was 17%. CONCLUSIONS: An increasing prevalence of DM was observed, while diet/light/zero beverages consumption remains stable. A substantial reduction in the annual percentage change of DM could be observed if people stopped consuming diet/light soda/juice.

The Association of Distinct Social Determinants of Health with Added Sweetener Knowledge and Consumption in a U.S. Sample of People Living with HIV.

Prior studies in people living with HIV (PLWH) suggest added sweetener intake exceeds recommendations and associates with cardiometabolic abnormalities. Little is known of factors that associate with increased sweetener consumption in PLWH. This cross-sectional study explored knowledge and consumption of added sweeteners and associations of social determinants of health (SDoH) among 900 PLWH residing in the United States. Demographics, SDoH, and added sweetener knowledge and consumption were assessed via an online survey, multivariable analyses were completed. Results demonstrate that sex, race, and low educational level associated with lower sweetener knowledge. Race, age, body mass index, income, limited access to fresh fruits/vegetables, and low sweetener knowledge associated with higher sweetener consumption. Findings highlight the need for consideration of specific demographics and inequitable social circumstances when developing nutrition lifestyle strategies, inclusive of added sweetener education, that are feasible and sustainable across diverse community settings of PLWH.

RESUMEN: Estudios previos en personas que viven con el VIH (PLWH) sugieren que la ingesta adicional de edulcorantes excede las recomendaciones y se asocia con anomalías cardiometabólicas. Poco se sabe de los factores que se asocian con un mayor consumo de edulcorantes en PLWH. Este estudio transversal exploró el conocimiento y el consumo de edulcorantes agregados y las asociaciones de los determinantes sociales de la salud (SDoH) entre 900 PLWH que residen en los Estado Unidos. Lo datos demográficos, SDoH, y en conocimiento y el consumo de edulcorantes añadidos se evaluaron mediante una encuesta en línea y se completaron análisis multivariables. Los resultados demuestran que el sexo, la raza y el bajo nivel educativo se asocian con un menor conocimiento sobre edulcorantes. Raza, edad, índice de masa corporal, ingresos, acceso limitado a frutas/verduras frescas y conocimiento bajo sobre edulcorantes asociado con un mayor consumo edulcorantes. Los hallazgos resaltan la necesidad de considerar la demografía específica y las circunstancias sociales desiguales al desarrollar estrategias de estilo de vida nutricional, incluida la educación adicional sobre edulcorantes, que sean factibles y sostenibles en diversos entornos comunitarios de PLWH.

Consumption of non-nutritive sweeteners by pre-schoolers of the food and environment Chilean cohort (FECHIC) before the implementation of the Chilean food labelling and advertising law.

BACKGROUND: Consumption of non-nutritive sweeteners (NNS) is becoming increasingly more frequent, particularly in the context of obesity prevention policies. The aim of this study was to describe the consumption of NNS in an ongoing cohort of pre-schoolers (4-6-year-old) before the implementation of the Chilean Food Labelling and Advertising Law, identify sociodemographic and anthropometric characteristics associated with their consumption, and describe the main dietary sources of each NNS sub-type. METHODS: In 959 low-medium income pre-schoolers from the Food and Environment Chilean Cohort (FECHIC), dietary data from a single 24-h recall was linked to NNS content information obtained from packaged foods (n = 12,233). The prevalence of NNS consumption was estimated by food source and characterized by child and maternal sociodemographic and anthropometric variables. Intakes and main dietary sources were described for the six most prevalent NNS in Chile: Sodium Cyclamate, Saccharin, Aspartame, Acesulfame Potassium, Sucralose, and Steviol glycosides. RESULTS: Sixty-eight percent of the pre-schoolers consumed at least one source of NNS on the day of the dietary recall; most of them consumed NNS from foods and beverages (n = 532), while only 12% (n = 119) also consumed table-top sweeteners. The prevalence of NNS consumption was significantly higher among children whose mothers had a high educational level compared to children whose mothers did not complete high school (p < 0.05); however, it did not differ by any other variable studied. The highest intakes of NNS were observed for Aspartame [2.5 (1.4-3.7) mg/kg per consumer], followed by Sodium Cyclamate [1.6 (1.3-2.6) mg/kg per consumer] and Steviol glycosides [1.2 (0.2-2.1) mg/kg per consumer]. Beverages were the only food group that contributed to the intake of the six NNS studied, accounting for 22% of the overall intake of Saccharine and up to 99% of Aspartame intake. CONCLUSIONS: Before the implementation of the Food Labelling and Advertising Law, NNS consumption was highly prevalent among a cohort of low-middle income Chilean pre-schoolers. Continuous monitoring of NNS consumption is essential given potential food reformulation associated with the implementation of this set of obesity-prevention policies.

Artificially Sweetened Beverages and Stroke, Coronary Heart Disease, and All-Cause Mortality in the Women's Health Initiative.

Background and Purpose- We examine the association between self-reported consumption of artificially sweetened beverages (ASB) and stroke and its subtypes, coronary heart disease, and all-cause mortality in a cohort of postmenopausal US women. Methods- The analytic cohort included 81 714 women from the Women's Health Initiative Observational Study, a multicenter longitudinal study of the health of 93 676 postmenopausal women of ages 50 to 79 years at baseline who enrolled in 1993 to 1998. This prospective study had a mean follow-up time of 11.9 years (SD of 5.3 years.) Participants who completed a follow-up visit 3 years after baseline were included in the study. Results- Most participants (64.1%) were infrequent consumers (never or <1/week) of ASB, with only 5.1% consuming ≥2 ASBs/day. In multivariate analyses, those consuming the highest level of ASB compared to never or rarely (<1/wk) had significantly greater likelihood of all end points (except hemorrhagic stroke), after controlling for multiple covariates. Adjusted models indicated that hazard ratios and 95% confidence intervals were 1.23 (1.02-1.47) for all stroke; 1.31 (1.06-1.63) for ischemic stroke; 1.29 (1.11-1.51) for coronary heart disease; and 1.16 (1.07-1.26) for all-cause mortality. In women with no prior history of cardiovascular disease or diabetes mellitus, high consumption of ASB was associated with more than a 2-fold increased risk of small artery occlusion ischemic stroke hazard ratio =2.44 (95% confidence interval, 1.47-4.04.) High consumption of ASBs was associated with significantly increased risk of ischemic stroke in women with body mass index ≥30; hazard ratio =2.03 (95% confidence interval, 1.38-2.98). Conclusions- Higher intake of ASB was associated with increased risk of stroke, particularly small artery occlusion subtype, coronary heart disease, and all-cause mortality. Although requiring replication, these new findings add to the potentially harmful association of consuming high quantities of ASB with these health outcomes.

EEG discrimination of perceptually similar tastes.

Perceptually similar stimuli, despite not being consciously distinguishable, may result in distinct cortical brain activations. Hypothesizing that perceptually similar tastes are discriminable by electroencephalography (EEG), we recorded 22 human participants' response to equally intense sweet-tasting stimuli: caloric sucrose, low-caloric aspartame, and a low-caloric mixture of aspartame and acesulfame K. Time-resolved multivariate pattern analysis of the 128-channel EEG was used to discriminate the taste responses at single-trial level. Supplementing the EEG study, we also performed a behavioral study to assess the participants' perceptual ability to discriminate the taste stimuli by a triangle test of all three taste pair combinations. The three taste stimuli were found to be perceptually similar or identical in the behavioral study, yet discriminable from 0.08 to 0.18 s by EEG analysis. Comparing the participants' responses in the EEG and behavioral study, we found that brain responses to perceptually similar tastes are discriminable, and we also found evidence suggesting that perceptually identical tastes are discriminable by the brain. Moreover, discriminability of brain responses was related to individual participants' perceptual ability to discriminate the tastes. We did not observe a relation between brain response discriminability and calorie content of the taste stimuli. Thus, besides demonstrating discriminability of perceptually similar and identical tastes with EEG, we also provide the first proof of a functional relation between brain response and perception of taste stimuli at individual level.

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.

Dietary intake of sugar substitutes aggravates cerebral ischemic injury and impairs endothelial progenitor cells in mice.

BACKGROUND AND PURPOSE: In our current food supply, sugar substitutes are widely used in beverages and other food products. However, there is limited information about the link between dietary consumption of sugar substitutes and stroke to date. This study sought to determine the effect of various sugar substitutes on the cerebral ischemic injury and endothelial progenitor cells, which have been implicated to play an important role in vascular repair and revascularization in ischemic brain tissues, in mice. METHODS: After treatment with sucrose and various sugar substitutes (the doses are in the range of corresponding acceptable daily intake levels) and vehicle for 6 weeks, mice were subjected to permanent left middle cerebral artery occlusion, and the infarct volumes, angiogenesis, and neurobehavioral outcomes were determined. In addition, the number and function of endothelial progenitor cells were also examined. RESULTS: After long-term treatment with fructose, erythritol (sugar alcohols), acesulfame K (artificial sweeteners), or rebaudioside A (rare sugars), the cerebral ischemic injury (both infarct volumes and neurobehavioral outcomes) was significantly aggravated, angiogenesis in ischemic brain was reduced, and endothelial progenitor cell function was impaired in mice compared with control. However, the similar impairments were not found in sucrose (with the same dose as fructose's)-treated mice. CONCLUSIONS: Long-term consumption of sugar substitutes aggravated cerebral ischemic injury in mice, which might be partly attributed to the impairment of endothelial progenitor cells and the reduction of angiogenesis in ischemic brain. This result implies that dietary intake of sugar substitutes warrants further attention in daily life.

Sugar-Sweetened Beverage Intake Is Positively Associated with Baseline Triglyceride Concentrations, and Changes in Intake Are Inversely Associated with Changes in HDL Cholesterol over 12 Months in a Multi-Ethnic Sample of Children.

BACKGROUND: Intake of sugar-sweetened beverages (SSBs) is linked to greater cardiometabolic risk in adults. Although longitudinal evidence is sparse among children, SSB intake reduction is targeted to reduce cardiometabolic risk factors in this group. OBJECTIVE: We investigated characteristics associated with consumption of SSBs in a multi-ethnic sample of children/adolescents and measured cross-sectional and longitudinal associations between SSB intake and plasma HDL cholesterol and triglycerides (TGs) over 12 mo. METHODS: In a diverse cohort of children aged 8-15 y, cross-sectional associations (n = 613) between baseline SSB intake and blood lipid concentrations and longitudinal associations (n = 380) between mean SSB intake, changes in SSB intake, and lipid changes over 12 mo were assessed with multivariable linear regression. RESULTS: Greater SSB intake was associated with lower socioeconomic status, higher total energy intake, lower fruit/vegetable intake, and more sedentary time. In cross-sectional analysis, greater SSB intake was associated with higher plasma TG concentrations among consumers (62.4, 65.3, and 71.6 mg/dL in children who consumed >0 but <2, ≥2 but <7, and ≥7 servings/wk, respectively; P-trend: 0.03); plasma HDL cholesterol showed no cross-sectional association. In the longitudinal analysis, mean SSB intake over 12 mo was not associated with lipid changes; however, the 12-mo increase in plasma HDL-cholesterol concentration was greater among children who decreased their intake by ≥1 serving/wk (4.6 ± 0.8 mg/dL) compared with children whose intake stayed the same (2.0 ± 0.8 mg/dL) or increased (1.5 ± 0.8 mg/dL; P = 0.02). CONCLUSIONS: In a multi-ethnic sample of children, intake of SSBs was positively associated with TG concentrations among consumers, and changes in SSB intake were inversely associated with HDL cholesterol concentration changes over 12 mo. Further research in large diverse samples of children is needed to study the public health implications of reducing SSB intake among children of different racial/ethnic groups. The Daily D Health Study was registered at clinicaltrials.gov as NCT01537809.

[Sweeteners: recent recommendations for health]. / Les édulcorants en question.

SWEETENERS: RECENT RECOMMENDATIONS FOR HEALTH. Intense sweeteners are compounds with a higher sweetening power than sugar. Their use has grown in industrial products and at home to reduce sugar intake, which is associated to health risks. In France, acesulfame K, aspartame, sucralose and Stevia are the most consumed sweeteners, included in table-top sweetener, sweets and chewing-gums, or diet beverages and dairy products. Their impact on health is still unclear. If some short-term benefits, as regards weight management for instance, have been observed, uncertainties remain regarding long-term effects, with studies reporting increased risks for several chronic diseases (cancer, cardiovascular diseases, diabetes). Hence, the World Health Organization recommends not to use them with objective to control weight or reduce chronic disease risk. Instead, efforts should be made to reduce the consumption of sugary products (with sugar or sweeteners) and to improve the nutritional quality of the diet.

LES ÉDULCORANTS EN QUESTION. Les édulcorants intenses sont des composés au pouvoir sucrant bien supérieur au sucre. Leur utilisation s'est développée dans les produits industriels ou à la maison pour réduire la consommation de sucre, qui est associée à des risques pour la santé. En France, les principaux édulcorants consommés sont l'acésulfame K, l'aspartame, le sucralose ou encore la stévia ; ils sont utilisés dans les sucrettes, les bonbons et chewing-gums, les boissons ou encore les produits laitiers light. Leurs effets sur la santé restent débattus. Si certains bénéfices à court terme peuvent être observés, notamment vis-à-vis du contrôle du poids, il existe des incertitudes quant à leurs effets à plus long terme, avec une augmentation de risque observée pour plusieurs pathologies (cancer, maladies cardiovasculaires, diabète). Ainsi, l'Organisation mondiale de la santé recommande de ne pas les utiliser en vue de contrôler son poids ou de réduire le risque de pathologie mais de plutôt s'attacher à réduire la consommation de produits sucrés (avec sucre ou édulcorants) et à améliorer la qualité nutritionnelle globale de l'alimentation.

An Overview of Reviews on the Association of Low Calorie Sweetener Consumption With Body Weight and Adiposity.

BACKGROUND: Numerous systematic reviews (SR) and meta-analyses (MA) on low calorie sweeteners (LCS) have been published in recent years, concluding that LCS have beneficial, neutral, or detrimental effects on various health outcomes, depending on the review. OBJECTIVES: The objective of this overview of reviews was to determine how the methodologies of SR investigating the association between LCS consumption and body weight (BW) influence their findings and whether MA results can provide a consistent estimated effect. METHODS: Systematic searches of PubMed, Scopus, and Cochrane Library were conducted in November 2022 to identify SR of randomized controlled trials (RCT) or non-randomized studies (NRS) investigating the association between LCS consumption and BW. The methods, MA results, and conclusions were extracted from each eligible SR. RESULTS: Of the 985 search results, 20 SR evaluated the association between LCS and BW, drawing from publications of 75 RCT, 42 prospective cohort studies, and 10 cross-sectional studies. There was a considerable lack of overlap of studies included within each SR attributed, in part, to the inclusion of studies based on design; thus, each SR synthesized results from distinctly different studies. Evidence synthesis methods were heterogeneous and often opaque, making it difficult to determine why results from certain studies were excluded or why disparate results were observed between SR. CONCLUSIONS: SR investigating the effect of LCS on BW implement different methodologies to answer allegedly the same question, drawing from a different set of heterogeneous studies, ignoring the basic assumptions required for MA, resulting in disparate results and conclusions. Previous MA show the large effects of study design, which results in inconsistent estimates of the effect of LCS on BW between MA of RCT and NRS. Given the availability of long-term RCT, these studies should be the basis of determining causal relationships (or lack thereof) between LCS and BW. This trial was registered at PROSPERO as CRD42022351200.

D-Tagatose: A Rare Sugar with Functional Properties and Antimicrobial Potential against Oral Species.

Carbohydrates have a dietary role, but excessive consumption of high-calorie sugars can contribute to an increased incidence of metabolic diseases and dental caries. Recently, carbohydrates with sweetening properties and low caloric value, such as D-tagatose, have been investigated as alternative sugars. D-tagatose is a rare sugar that has nutritional and functional properties of great interest for health. This literature review presents an approach to the biological effects of D-tagatose, emphasizing its benefits for oral health. Studies report that D-tagatose has antioxidant and prebiotic effects, low digestibility, reduced glycemic and insulinemic responses, and the potential to improve the lipid profile, constituting an alternative for diabetes mellitus and obesity. It can also be observed that D-tagatose has an antioxidant action, favoring the elimination of free radicals and, consequently, causing a reduction in cellular oxidative stress. Furthermore, it also has antibacterial potential against oral species. Regarding oral health, studies have shown that D-tagatose efficiently reversed bacterial coaggregations, including periodontopathogenic species, and impaired the activity and growth of cariogenic bacteria, such as S. mutans. D-tagatose significantly inhibited biofilm formation, pH decrease and insoluble glucan synthesis in S. mutans cultures. Salivary S. mutans counts were also significantly reduced by the consumption of chewing gum containing D-tagatose and xylitol. In addition, there is evidence that tagatose is effective as an air-polishing powder for biofilm decontamination. The literature indicates that D-tagatose can contribute to the prevention of systemic diseases, also constituting a promising agent to improve oral health.

The effect of different sweeteners on the oral microbiome: a randomized clinical exploratory pilot study.

Introduction: The aim of the study was to evaluate the modulating effects of five commonly used sweetener (glucose, inulin, isomaltulose, tagatose, trehalose) containing mouth rinses on the oral microbiome. Methods: A single-centre, double-blind, parallel randomized clinical trial was performed with healthy, 18-55-year-old volunteers (N = 65), who rinsed thrice-daily for two weeks with a 10% solution of one of the allocated sweeteners. Microbiota composition of supragingival dental plaque and the tongue dorsum coating was analysed by 16S RNA gene amplicon sequencing of the V4 hypervariable region (Illumina MiSeq). As secondary outcomes, dental plaque red fluorescence and salivary pH were measured. Results: Dental plaque microbiota changed significantly for two groups: inulin (F = 2.0239, p = 0.0006 PERMANOVA, Aitchison distance) and isomaltulose (F = 0.67, p = 0.0305). For the tongue microbiota, significant changes were observed for isomaltulose (F = 0.8382, p = 0.0452) and trehalose (F = 1.0119, p = 0.0098). In plaque, 13 species changed significantly for the inulin group, while for tongue coating, three species changed for the trehalose group (ALDEx2, p < 0.1). No significant changes were observed for the secondary outcomes. Conclusion: The effects on the oral microbiota were sweetener dependant with the most pronounced effect on plaque microbiota. Inulin exhibited the strongest microbial modulating potential of the sweeteners tested. Further full-scale clinical studies are required.

Effect of sweetened beverages intake on salivary aspartame, insulin and alpha-amylase levels: A single-blind study.

The objective was to assess aspartame excretion in saliva and the salivary insulin, total protein (TP), and alpha-amylase (AMI) levels in response to the ingestion of sweetened beverages (sodium cyclamate, aspartame, acesulfame, and sucrose). Fifteen healthy participants were included in a single-blinded trial with the intake of Diet soft drink, Regular soft drink, Water + sweeteners, Low sucrose content (3.5 g), and Water (blank) in 5 different days. In each day, saliva was collected at T0 (fasting), T1 (15 min after test-drink intake), T2 (30 min), T3 (60 min), and T4 (120 min) for the measurement of salivary aspartame (HPLC), TP, AMI (ELISA assays) and insulin levels (chemiluminescence). Chi-square, Friedman, ANOVA and Spearman correlation tests were applied. The late-perceived sweet/sour residual flavor was reported at a frequency of 80%, 60% and 20% after ingestion of artificially sweetened drinks, beverages with sucrose, and plain water, respectively (p < 0.05). Aspartame was detected in saliva after artificially sweetened drinks intake, with highest area under the peak for the Diet soft drink (p = 0.014). No change was observed for TP and AMI levels during the 120 min. Insulin levels increased 1 h after soft-drinks ingestion (regular and diet), while the levels did not change for Low sucrose content and Water + sweeteners test-drinks. Salivary aspartame correlated with insulin levels only after Diet soft drink intake (rho ≥ 0.7; p < 0.05). As aspartame can be detected in saliva and swallowed again until completely excreted, these results contribute to the knowledge of the biological fate of artificial sweeteners and the study of health outcomes.

Examining the Usage Patterns of Non-Nutritive Sweeteners among Non-Diabetic Individuals: Insights from the Longitudinal Study of Adult Health (ELSA-Brasil).

BACKGROUND: Although non-nutritive sweeteners (NNSs) were formulated primarily for sugar-restricted diets, nowadays, their consumption has become widespread among the general population. Thus, the purpose of this study was to estimate the prevalence of the regular use of NNSs and their associated factors among non-diabetic individuals from the baseline of the Longitudinal Study of Adult Health (ELSA-Brasil). METHODS: In total, 9226 individuals were analysed, and the regular consumption of NNSs was defined as follows: NSSs are used at least once a day. Associations between exposure and outcomes were analysed using chi-square and Student's t-tests. Significant variables were inserted into a binary logistic regression model to determine the adjusted association measures (significance level of 5%). RESULTS: The prevalence of regular NNS consumption was 25.7%. Regular NNS consumption increased with age, categories of BMI, income, and schooling. The odds of regularly consuming NNSs were 1.9-times higher among women, 6.1-times higher among obese individuals, and 1.8-times higher among those with higher schooling and income. CONCLUSIONS: Specific groups seem to present a larger association relative to the use of NNS. Based on the significant overall prevalence of the regular use of NNSs, a discussion regarding country-wide policies related to their intake is needed to address recent WHO directions concerning this additive.

Artificial Sweeteners: Perceptions and Realities.

Artificial sweeteners (AS) were first introduced as food additives or sugar substitutes more than a century ago with the intention of supplying sweet taste without the high caloric content of sugar. AS are employed in place of sucrose (table sugar) with the view of providing sweetness to foodstuffs and bottled drinks. The end-users, along with producers of canned food and drinks, have long been captivated by the idea of replacing sugar in food items with AS. Foods that use AS in place of sugar have become increasingly common during the past decade. Artificial sugars are normally many folds sweeter than normal sugar possessing low or zero calories, which confers to their public appeal for the management of overweight issues. Due to this, they are, at present, employed by many individuals all over the world, without knowing the potential hazards associated with them. The use of AS in obese, diabetic, and/or heart patients or patients with metabolic syndrome has been approved with caution by The American Heart Association and American Diabetes Association (ADA) as a low-calorie option for normal sugar. Judicious use of sugar substitutes can help in maintaining blood glucose, calories and body weight, thus automatically minimizing the risk factors of diabetes and heart disease. Since the day of their discovery and approval, their safety issue has been quite controversial and debated extensively. The article follows an exhaustive review discussing the history, uses, and chemical features of a wide variety of sweeteners with a focus on their association with diabetes and potential adverse effects on the body.

Sweetener Purchases in Chile before and after Implementing a Policy for Food Labeling, Marketing, and Sales in Schools.

Background: Chile's landmark food labeling and advertising policy led to major reductions in sugar purchases. However, it is unclear whether this led to increases in the purchases of nonnutritive sweeteners (NNS). Objectives: The objective of this study was to assess the changes in NNS and caloric-sweetened (CS) products purchased after the law's first phase. Methods: Longitudinal data on food and beverage purchases from 2,381 households collected from January 1, 2015 to December 31, 2017, were linked to nutritional information and categorized into added sweetener groups (unsweetened, NNS-only, CS-only, or NNS with CS). Logistic random-effects models and fixed-effects models were used to compare the percentage of households purchasing products and the mean volume purchased by sweetener category to a counterfactual based on pre-regulation trends. Results: Compared with the counterfactual, the percentage of households purchasing any NNS beverages (NNS-only or NNS with CS) increased by 4.2 percentage points (pp) (95% CI: 2.8, 5.7; P < 0.01). This increase was driven by households purchasing NNS-only beverages (12.1 pp, 95% CI: 10.0, 14.2; P < 0.01). The purchased volume of beverages with any NNS increased by 25.4 mL/person/d (95% CI: 20.1, 30.7; P < 0.01) or 26.5%. Relative to the counterfactual, there were declines of -5.9 pp in households purchasing CS-only beverages (95% CI: -7.0, -4.7; P < 0.01). Regarding the types of sweeteners purchased, we found significant increases in the amounts of sucralose, aspartame, acesulfame K, and steviol glycosides purchased from beverages. Among foods, differences were minimal. Conclusions: The first phase of Chile's law was associated with an increase in the purchases of beverages containing NNS and decreases in beverages containing CS, but virtually no changes in foods.

Rationale, Design and Participants Baseline Characteristics of a Crossover Randomized Controlled Trial of the Effect of Replacing SSBs with NSBs versus Water on Glucose Tolerance, Gut Microbiome and Cardiometabolic Risk in Overweight or Obese Adult SSB Consumer: Strategies to Oppose SUGARS with Non-Nutritive Sweeteners or Water (STOP Sugars NOW) Trial and Ectopic Fat Sub-Study.

BACKGROUND: Health authorities are near universal in their recommendation to replace sugar-sweetened beverages (SSBs) with water. Non-nutritive sweetened beverages (NSBs) are not as widely recommended as a replacement strategy due to a lack of established benefits and concerns they may induce glucose intolerance through changes in the gut microbiome. The STOP Sugars NOW trial aims to assess the effect of the substitution of NSBs (the "intended substitution") versus water (the "standard of care substitution") for SSBs on glucose tolerance and microbiota diversity. DESIGN AND METHODS: The STOP Sugars NOW trial (NCT03543644) is a pragmatic, "head-to-head", open-label, crossover, randomized controlled trial conducted in an outpatient setting. Participants were overweight or obese adults with a high waist circumference who regularly consumed ≥1 SSBs daily. Each participant completed three 4-week treatment phases (usual SSBs, matched NSBs, or water) in random order, which were separated by ≥4-week washout. Blocked randomization was performed centrally by computer with allocation concealment. Outcome assessment was blinded; however, blinding of participants and trial personnel was not possible. The two primary outcomes are oral glucose tolerance (incremental area under the curve) and gut microbiota beta-diversity (weighted UniFrac distance). Secondary outcomes include related markers of adiposity and glucose and insulin regulation. Adherence was assessed by objective biomarkers of added sugars and non-nutritive sweeteners and self-report intake. A subset of participants was included in an Ectopic Fat sub-study in which the primary outcome is intrahepatocellular lipid (IHCL) by 1H-MRS. Analyses will be according to the intention to treat principle. BASELINE RESULTS: Recruitment began on 1 June 2018, and the last participant completed the trial on 15 October 2020. We screened 1086 participants, of whom 80 were enrolled and randomized in the main trial and 32 of these were enrolled and randomized in the Ectopic Fat sub-study. The participants were predominantly middle-aged (mean age 41.8 ± SD 13.0 y) and had obesity (BMI of 33.7 ± 6.8 kg/m2) with a near equal ratio of female: male (51%:49%). The average baseline SSB intake was 1.9 servings/day. SSBs were replaced with matched NSB brands, sweetened with either a blend of aspartame and acesulfame-potassium (95%) or sucralose (5%). CONCLUSIONS: Baseline characteristics for both the main and Ectopic Fat sub-study meet our inclusion criteria and represent a group with overweight or obesity, with characteristics putting them at risk for type 2 diabetes. Findings will be published in peer-reviewed open-access medical journals and provide high-level evidence to inform clinical practice guidelines and public health policy for the use NSBs in sugars reduction strategies. TRIAL REGISTRATION: ClinicalTrials.gov identifier, NCT03543644.

Dental Erosion: Effect of Diet Drink Consumption on Permanent Dentition.

OBJECTIVE: The aim of this study is to examine the effect of diet drinks on dental erosion among a representative sample of US adults. METHODS: Adult dietary and dental data were analyzed from the 2003-2004 cycle of the National Health and Nutrition Examination Survey. Erosion was measured with a modified tooth wear index and was analyzed as a dichotomous variable. Cluster analysis was performed, and the cluster number was based on having a separate diet drink cluster and the R2 values. Survey procedure and sample weights were used. RESULTS: Most of the population (80%) had some form of dental erosive lesions. When compared with the total sample, people with erosion were more likely to be male (52.5%) and older. People with no erosive lesions were younger (42.3%) and non-Hispanic Black (21.2%). Cluster analysis resulted in 4 distinct clusters: high water, high diet drinks, high coffee/tea, and high soda. The respective percentage of individuals in each cluster who had erosion was 78.9%, 85%, 83.9%, and 76.2%, where the "high diet drinks" cluster showed the highest erosion (P = 0.28). Logistic regression modeling showed that the "high diet drinks" cluster had increased odds of erosion (odds ratio = 1.27; 95% CI = 0.58 to 2.77) when compared with the "high water" cluster, but the relationship was not statistically significant. CONCLUSION: High diet drinks consumption slightly increased the odds of dental erosion among US adults, although this relationship was not statistically significant. It is thus not yet clear that dentists should recommend diet drinks, as they might be linked to systemic diseases. Further research is needed to explore more about risk factors of erosion. KNOWLEDGE TRANSFER STATEMENT: The findings of this study are suggestive, though not significantly, that diet drinks may increase risk for dental erosion. While further research is needed, it is not clear that dentists should recommend these drinks as healthy substitutes for sugary drinks.

Added sugars and non-nutritive sweeteners in the food supply: Are they a threat for consumers?

BACKGROUND & AIMS: Excess sugar intake can cause chronic diseases such as obesity, diabetes, and cardiovascular disease. Thus, limiting the intake of sugar in the diet is an important preventive measure. Food manufacturers have considered non-nutritive sweeteners (NNS) as an alternative to sugars. To date, there has been no systematic monitoring of the types of added sugars and NNS in Turkey's food supply. The aim of this study identified the added sugars and NNS in packaged foods and beverages that were available in supermarkets across Turkey. METHODS: A cross-sectional study was conducted from April to December 2020. Three supermarkets in Turkey were chosen for this study. RESULTS: Of the 2514 packaged foods and beverages analyzed, 1647 (65.5%) contained added sugars or NNS. Out of 1647 products, 9.7% contained both added sugars and NNS; 86.5% only added sugars whereas 3.8% had only NNS. The most used added sugar was white sugar in all food groups (50.6%-100%) while the most used NNS was sorbitol (28.4%). CONCLUSION: The use of added sugars and NNS in Turkey's food supply was found to be high, and white sugar being the most used sweetener in products available in the food supply. Therefore, it may be important to start monitoring the prevalence of products containing added sugars and NNS due to their negative health effects.

Changes in nonnutritive sweetener intake in a cohort of preschoolers after the implementation of Chile's Law of Food Labelling and Advertising.

BACKGROUND: The first phase of Chile's Law of Food Labelling and Advertising showed important declines in the sugar content of packaged foods, but it is unknown whether the law led to an increase in nonnutritive sweetener (NNS) intake, particularly among preschool children. OBJECTIVES: Estimate the changes in preschoolers' NNS intake after the first phase of the Chilean law. METHODS: We used 24-h dietary recalls collected in 2016 (pre-law) and 2017 (post-law) from a cohort of preschoolers (n = 875). The primary caretaker was the respondent of the recalls. Information on NNS was obtained from nutrition facts panels collected annually and linked to dietary data. We used logistic regression to estimate the changes in the proportion of preschoolers who consume NNS and two-part models to estimate the changes in mean intake. We determined the percentage of children that surpassed the acceptable daily intake (ADI) of each NNS using the National Cancer Institute method. RESULTS: The proportion of consumers of at least one NNS increased from 77.9% to 92.0% (p-value < 0.01). The mean intake increased for sucralose, aspartame, acesulfame-K and steviol glycosides (+20.3, +15.1, +6.1 and +3.3 mg/day, respectively). In addition, NNS dietary sources changed for sucralose and steviol glycosides, becoming industrialized juices and dairy beverages more relevant while tabletop NNS became less relevant. None of the children surpassed the ADI. CONCLUSIONS: NNS intake increased in preschoolers after the first phase of a national policy that promoted sugar reformulation.