Do sugar-sweetened beverages cause adverse health outcomes in children? A systematic review protocol High-fructose corn syrup and sucrose have equivalent effects on energy-regulating hormones at normal human consumption levels. The Effect of Normally Consumed Amounts of Sucrose or High Fructose Corn Syrup on Lipid Profiles, Body Composition and Related Parameters in Overweight/Obese Subjects A prospective study of sugar intake and risk of type 2 diabetes in women. The 2015 Dutch food-based dietary guidelines Sugars and risk of mortality in the NIH-AARP Diet and Health Study. Consumption of fructose- but not glucose-sweetened beverages for 10 weeks increases circulating concentrations of uric acid, retinol binding protein-4, and gamma-glutamyl transferase activity in overweight/obese humans Prospective Study of Pre-Gravid Sugar-Sweetened Beverage Consumption and the Risk of Gestational Diabetes Mellitus No Effect of Added Sugar Consumed at Median American Intake Level on Glucose Tolerance or Insulin Resistance Modeling the Effect of Replacing Sugar-Sweetened Beverage Consumption with Water on Energy Intake, HBI Score, and Obesity Prevalence Sweetened Beverage Consumption, Incident Coronary Heart Disease, and Biomarkers of Risk in Men Sugar-Sweetened Beverage Health Warnings and Purchases: A Randomized Controlled Trial. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. Controversies around Xylitol High glycemic index diet as a risk factor for depression: analyses from the Women's Health Initiative. No difference in ad libitum energy intake in healthy men and women consuming beverages sweetened with fructose, glucose, or high-fructose corn syrup: a randomized trial. The Effects of Physiologic Amounts of Simple Sugars on Lipoprotein, Glucose, and Insulin Levels in Normal Subjects Sugar-added beverages and adolescent weight change. Added sugar intake and cardiovascular diseases mortality among US adults. Is carbohydrate intake in the first years of life related to future risk of NCDs? Effects of dietary fructose on plasma lipids in healthy subjects.
Background Cardiovascular disease and type 2 diabetes are examples of chronic diseases that impose significant morbidity and mortality in the general population worldwide . Most chronic diseases are associated with underlying preventable risk factors , such as elevated blood pressure , high blood glucose or glucose intolerance , high lipid levels , physical inactivity , excessive sedentary behaviours , and overweight/obesity . The occurrence of intermediate outcomes during childhood increases the risk of disease in adulthood . Sugar-sweetened beverages are known to be significant sources of additional caloric intake , and given recent attention to their contribution in the development of chronic diseases , a systematic review is warranted . We will assess whether the consumption of sugar-sweetened beverages in children is associated with adverse health outcomes and what the potential moderating factors are . Methods / Design Of interest are studies addressing sugar-sweetened beverage consumption , taking a broad perspective . Both direct consumption studies as well as those evaluating interventions that influence consumption ( e.g. school policy , educational ) will be relevant . Non-specific or multi-faceted behavioural , educational , or policy interventions may also be included subject to the level of evidence that exists for the other interventions /exposures . Comparisons of interest and endpoints of interest are pre-specified . We will include r and omized controlled trials , controlled clinical trials , interrupted time series studies , controlled before-after studies , prospect i ve and retrospective comparative cohort studies , case – control studies , and nested case – control design s. The MEDLINE ® , Embase , The Cochrane Library , CINAHL , ERIC , and PsycINFO ® data bases and grey literature sources will be search ed . The processes for selecting studies , abstract ing data , and resolving conflicts are described . We will assess risk of bias using design -specific tools . To determine sets of confounding variables that should be adjusted for , we have developed causal directed acyclic graphs and will use those to inform our risk of bias assessment s. Meta- analysis will be conducted where appropriate ; parameters for exploring statistical heterogeneity and effect modifiers are pre-specified . The Grading of Recommendations Assessment , Development and Evaluation ( GRADE ) approach will be used to determine the quality of evidence for outcomes . Systematic review registration PROSPERO CRD42014009641 Intake of high-fructose corn syrup ( HFCS ) has been suggested to contribute to the increased prevalence of obesity , whereas a number of studies and organizations have reported metabolic equivalence between HFCS and sucrose . We hypothesized that HFCS and sucrose would have similar effects on energy-regulating hormones and metabolic substrates at normal levels of human consumption and that these values would not change over a 10-week , free-living period at these consumption levels . This was a r and omized , prospect i ve , double-blind , parallel group study in which 138 adult men and women consumed 10 weeks of low-fat milk sweetened with either HFCS or sucrose at levels of the 25th , 50th , and 90th percentile population consumption of fructose ( the equivalent of 40 , 90 , or 150 g of sugar per day in a 2000-kcal diet ) . Before and after the 10-week intervention , 24-hour blood sample s were collected . The area under the curve ( AUC ) for glucose , insulin , leptin , active ghrelin , triglyceride , and uric acid was measured . There were no group differences at baseline or posttesting for all outcomes ( interaction , P > .05 ) . The AUC response of glucose , active ghrelin , and uric acid did not change between baseline and posttesting ( P > .05 ) , whereas the AUC response of insulin ( P < .05 ) , leptin ( P < .001 ) , and triglyceride ( P < .01 ) increased over the course of the intervention when the 6 groups were averaged . We conclude that there are no differences in the metabolic effects of HFCS and sucrose when compared at low , medium , and high levels of consumption The American Heart Association ( AHA ) has advocated that women and men not consume more than 100 and 150 kcal/day , respectively , from added sugars . These levels are currently exceeded by over 90 % of the adult population in the United States . Few data exist on longer-term metabolic effects when sucrose and High Fructose Corn Syrup ( HFCS ) , the principal sources of added dietary sugars , are consumed at levels typical of the general population . Sixty five overweight and obese individuals were placed on a eucaloric ( weight stable ) diet for 10-weeks , which incorporated sucrose- or HFCS-sweetened , low-fat milk at 10 % or 20 % of calories in a r and omized , double-blinded study . All groups responded similarly ( interaction p > 0.05 ) . There was no change in body weight in any of the groups over the 10-week study , or in systolic or diastolic blood pressure . Likewise , there were no changes in total cholesterol , triglycerides , low-density lipoprotein ( LDL ) , or apolipoprotein B ( Apo B ) . We conclude that ( 1 ) when consumed as part of a eucaloric diet fructose — when given with glucose ( as normally consumed ) does not promote weight gain or an atherogenic lipid profile even when consumed at two to four times the level recently recommended by the AHA . ( 2 ) There were no differences between HFCS and sucrose on these parameters OBJECTIVE To investigate prospect ively whether intake of total or type of sugar is associated with the risk of developing type 2 diabetes . The contribution of sugar intake to the pathogenesis of type 2 diabetes has not been settled in the context of primary prevention because of limited prospect i ve data . RESEARCH DESIGN AND METHODS The Women 's Health Study is a r and omized controlled trial of aspirin and vitamin E in the prevention of cardiovascular disease and cancer . A vali date d semiquantitative food frequency question naire was completed by 39,345 women aged 45 years and older . The main outcome was the incidence of type 2 diabetes . The predictor was sugar intake , including sucrose , glucose , fructose , and lactose . Using Cox proportional hazard models , multivariate RRs of type 2 diabetes for increasing quintiles of sugar intake compared with the lowest quintile were estimated . RESULTS Compared with the lowest quintile of sugar intake , the RRs and 95 % CIs for the highest quintiles were 0.84 ( 0.67 - 1.04 ) for sucrose , 0.96 ( 0.78 - 1.19 ) for fructose , 1.04 ( 0.85 - 1.28 ) for glucose , and 0.99 ( 0.80 - 1.22 ) for lactose , after adjustment for known risk factors for type 2 diabetes . Similar findings of no association were obtained in subgroup analyses stratified by BMI . CONCLUSIONS Intake of sugars does not appear to play a deleterious role in primary prevention of type 2 diabetes . These prospect i ve data support the recent American Diabetes Association 's guideline that a moderate amount of sugar can be incorporated in a healthy diet The objective of this study was to derive food-based dietary guidelines for the Dutch population . The dietary guidelines are based on 29 systematic review s of English language meta-analyses in PubMed summarizing r and omized controlled trials and prospect i ve cohort studies on nutrients , foods and food patterns and the risk of 10 major chronic diseases : coronary heart disease , stroke , heart failure , diabetes , breast cancer , colorectal cancer , lung cancer , chronic obstructive pulmonary disease , dementia and depression . The committee also selected three causal risk factors for cardiovascular diseases or diabetes : systolic blood pressure , low-density lipoprotein cholesterol and body weight . Findings were categorized as strong or weak evidence , inconsistent effects , too little evidence or effect unlikely for experimental and observational data separately . Next , the committee selected only findings with a strong level of evidence for deriving the guidelines . Convincing evidence was based on strong evidence from the experimental data either or not in combination with strong evidence from prospect i ve cohort studies . Plausible evidence was based on strong evidence from prospect i ve cohort studies only . A general guideline to eat a more plant food-based dietary pattern and limit consumption of animal-based food and 15 specific guidelines have been formulated . There are 10 new guidelines on legumes , nuts , meat , dairy produce , cereal products , fats and oils , tea , coffee and sugar-containing beverages . Three guidelines on vegetables , fruits , fish and alcoholic beverages have been sharpened , and the 2006 guideline on salt stayed the same . A separate guideline has been formulated on  nutrient supplements .  Completely food-based dietary guidelines can be derived in a systematic and transparent way BACKGROUND Although previous studies have linked intake of sugars with incidence of cancer and other chronic diseases , its association with mortality remains unknown . OBJECTIVE We investigated the association of total sugars , added sugars , total fructose , added fructose , sucrose , and added sucrose with the risk of all-cause , cardiovascular disease , cancer , and other-cause mortality  in the NIH-AARP Diet and Health Study . DESIGN The participants ( n = 353,751 ) , aged 50 - 71 y , were followed for up to 13 y. Intake of individual sugars over the previous 12 mo was assessed at baseline by using a 124-item NIH Diet History Question naire . RESULTS In fully adjusted models ( fifth quartile compared with first quartile ) , all-cause mortality was positively associated with the intake of total sugars [ HR ( 95 % CI ) : 1.13 ( 1.06 , 1.20 ) ; P-trend < 0.0001 ] , total fructose [ 1.10 ( 1.04 , 1.17 ) ; P-trend < 0.0001 ] , and added fructose [ 1.07 ( 1.01 , 1.13 ) ; P-trend = 0.005 ) in women and total fructose [ 1.06 ( 1.01 , 1.10 ) ; P-trend = 0.002 ] in men . In men , a weak inverse association was found between other-cause mortality and dietary added sugars  ( P-trend = 0.04 ) , sucrose ( P-trend = 0.03 ) , and added sucrose ( P-trend = 0.006 ) . Investigation of consumption of sugars by source showed that the positive association with mortality risk was confined only to sugars from beverages , whereas the inverse association was confined to sugars from solid foods . CONCLUSIONS In this large prospect i ve study , total fructose intake was weakly positively associated with  all-cause mortality in both women and men , whereas added sugar , sucrose , and added sucrose intakes were inversely associated with other-cause mortality in men . In our analyses , intake of added sugars was not associated with an increased risk of mortality . The NIH-AARP Diet and Health Study was registered at clinical trials.gov as NCT00340015 Background Prospect i ve studies in humans examining the effects of fructose consumption on biological markers associated with the development of metabolic syndrome are lacking . Therefore we investigated the relative effects of 10 wks of fructose or glucose consumption on plasma uric acid and RBP-4 concentrations , as well as liver enzyme ( AST , ALT , and GGT ) activities in men and women . Methods As part of a parallel arm study , older ( age 40–72 ) , overweight and obese male and female subjects ( BMI 25–35 kg/m2 ) consumed glucose- or fructose-sweetened beverages providing 25 % of energy requirements for 10 wks . Fasting and 24-h blood collection s were performed at baseline and following 10 wks of intervention and plasma concentrations of uric acid , RBP-4 and liver enzyme activities were measured . Results Consumption of fructose , but not glucose , led to significant increases of 24-h uric acid profiles ( P < 0.0001 ) and RBP-4 concentrations ( P = 0.012 ) , as well as plasma GGT activity ( P = 0.04 ) . Fasting plasma uric acid concentrations increased in both groups ; however , the response was significantly greater in subjects consuming fructose ( P = 0.002 for effect of sugar ) . Within the fructose group male subjects exhibited larger increases of RBP-4 levels than women ( P = 0.024 ) . Conclusions These findings suggest that consumption of fructose at 25 % of energy requirements for 10 wks , compared with isocaloric consumption of glucose , may contribute to the development of components of the metabolic syndrome by increasing circulating uric acid , GGT activity , suggesting alteration of hepatic function , and the production of RBP-4 OBJECTIVE Consumption of sugar-sweetened beverages ( SSBs ) was related to an elevated risk of type 2 diabetes and insulin resistance in several recent studies among middle- or older-aged population s. Studies on SSB consumption and glucose intolerance among pregnant women , however , are lacking . We therefore examined the association between regular SSB consumption before pregnancy and the risk of gestational diabetes mellitus ( GDM ) . RESEARCH DESIGN AND METHODS This was a prospect i ve study among 13,475 U.S. women who reported at least one singleton pregnancy between 1992 and 2001 in the Nurses ' Health Study II . GDM was self-reported and vali date d by medical record review in a sub sample . Cox proportional hazards models with multivariate adjustments were applied to examine the association of SSB consumption with GDM risk . RESULTS During 10 years of follow-up , 860 incident GDM case subjects were identified . After adjustment for age , parity , race , physical activity , smoking , alcohol intake , prepregnancy BMI , and Western dietary pattern , intake of sugar-sweetened cola was positively associated with the risk of GDM , whereas no significant association was found for other SSBs and diet beverages . Compared with women who consumed < 1 serving/month , those who consumed ≥5 servings/week of sugar-sweetened cola had a 22 % greater GDM risk ( relative risk 1.22 [ 95 % CI 1.01–1.47 ] ) . CONCLUSIONS Findings from this study suggest that prepregnancy higher consumption of sugar-sweetened cola ( ≥5 servings/week ) is associated with an elevated GDM risk , whereas no significant association with GDM risk was observed for other SSBs and diet beverages Excess sugar consumption may promote adverse changes in  hepatic and total body insulin resistance .  Debate continues over the effects of sugars at more typically consumed levels and whether the identity of the sugar consumed is important . In the present study participants ( 20–60 years old ) were r and omly assigned to one of five groups , three that consumed low fat milk with added fructose containing sugars in amounts equivalent to the 50th percentile of fructose consumption ( US ) , one which consumed low-fat milk sweetened with glucose , and one unsweetened low-fat milk control group . The intervention lasted ten weeks . In the entire study population there was less than 1 kg increase in weight ( 73.6 ± 13.0 vs. 74.5 ± 13.3 kg , p < 0.001 ) , but the change in weight was comparable among groups ( p > 0.05 ) . There were no changes in fasting glucose ( 49 ± 0.4 vs. 5.0 ± 0.5 mmol/L ) , insulin ( 56.9 ± 38.9 vs. 61.8 ± 50.0 pmol/L ) , or insulin resistance , as measured by the Homeostasis Model Assessment method ( 1.8 ± 1.3 vs. 2.0 ± 1.5 , all p > 0.05 ) . These data suggest that added sugar consumed at the median American intake level does not produce changes in measures of insulin sensitivity or glucose tolerance and that no sugar has more deleterious effects than others Sugar-sweetened beverages ( SSB ) contribute to excessive weight gain through added energy intake . Replacing SSB with water is one strategy that has shown promise in helping lower excessive energy intake . Using nationally representative data from US adults ( n = 19,718 ) from NHANES 2007–2012 we examine the impact of replacing SSB with water on Healthy Beverage Index ( HBI ) scores and obesity prevalence . Replacing an 8-ounce serving of SSB with water lowered the percent of energy from beverages from 17 % to 11 % ( among those consuming 1 serving SSB/day ) . Reductions in the percent energy from beverages were observed across all SSB consumption groups ( 1–2 servings/day and > 2 servings/day ) . Among adults there was a 9 % to 21 % improvement in HBI score when one serving of water replaced one serving of SSB . Using previously published r and omized controlled trials ( RCT ) and meta-analyses of measured weight loss we also predicted a reduction in the prevalence of obesity ( observed : 35.2 % ; predicted 33.5%–34.9 % , p < 0.05 ) and increase in the prevalence of normal weight ( observed : 29.7 % ; high weight loss : 31.3 % , p < 0.05 ) . Our findings provide further epidemiologic evidence that water in the place of SSB can be used as a strategy to limit energy intake and help individuals meet beverage intake recommendations Background — Sugar-sweetened beverage consumption is associated with weight gain and risk of type 2 diabetes mellitus .  Few studies have tested for a relationship with coronary heart disease ( CHD ) or intermediate biomarkers . The role of artificially sweetened beverages is also unclear . Methods and Results — We performed an analysis of the Health Professionals Follow-Up Study , a prospect i ve cohort study including 42 883 men . Associations of cumulatively averaged sugar-sweetened ( eg , sodas ) and artificially sweetened ( eg , diet sodas ) beverage intake with incident fatal and nonfatal CHD ( myocardial infa rct ion ) were examined with proportional hazard models . There were 3683 CHD cases over 22 years of follow-up . Participants in the top quartile of sugar-sweetened beverage intake had a 20 % higher relative risk of CHD than those in the bottom quartile ( relative risk=1.20 ; 95 % confidence interval , 1.09–1.33 ; P for trend < 0.01 ) after adjustment for age , smoking , physical activity , alcohol , multivitamins , family history , diet quality , energy intake , body mass index , pre-enrollment weight change , and dieting . Artificially sweetened beverage consumption was not significantly associated with CHD ( multivariate relative risk=1.02 ; 95 % confidence interval , 0.93–1.12 ; P for trend=0.28 ) . Adjustment for self-reported high cholesterol , high triglycerides , high blood pressure , and diagnosed type 2 diabetes mellitus slightly attenuated these associations . Intake of sugar-sweetened but not artificially sweetened beverages was significantly associated with increased plasma triglycerides , C-reactive protein , interleukin-6 , and tumor necrosis factor receptors 1 and 2 and decreased high-density lipoprotein , lipoprotein(a ) , and leptin ( P<0.02 ) . Conclusions — Consumption of sugar-sweetened beverages was associated with increased risk of CHD and some adverse changes in lipids , inflammatory factors , and leptin . Artificially sweetened beverage intake was not associated with CHD risk or biomarkers INTRODUCTION Five U.S. states have proposed policies to require health warnings on sugar-sweetened beverages , but warnings ' effects on actual purchase behavior remain uncertain . This study evaluated the impact of sugar-sweetened beverage health warnings on sugar-sweetened beverage purchases . STUDY DESIGN Participants completed one study visit to a life-sized replica of a convenience store in North Carolina . Participants chose six items ( two beverages , two foods , and two household products ) . One item was r and omly selected for them to purchase and take home . Participants also completed a question naire . Research ers collected data in 2018 and conducted analyses in 2019 . SETTING / PARTICIPANTS Participants were a demographically diverse convenience sample of 400 adult sugar-sweetened beverage consumers ( usual consumption ≥12 ounces/week ) . INTERVENTION Research staff r and omly assigned participants to a health warning arm ( sugar-sweetened beverages in the store displayed a front-of-package health warning ) or a control arm ( sugar-sweetened beverages displayed a control label ) . MAIN OUTCOME MEASURES The primary trial outcome was sugar-sweetened beverage calories purchased . Secondary outcomes included reactions to trial labels ( e.g. , negative emotions ) and sugar-sweetened beverage perceptions and attitudes ( e.g. , healthfulness ) . RESULTS All 400 participants completed the trial and were included in analyses . Health warning arm participants were less likely to be Hispanic and to have overweight/obesity than control arm participants . In intent-to-treat analyses adjusting for Hispanic ethnicity and overweight/obesity , health warnings led to lower sugar-sweetened beverage purchases ( adjusted difference , -31.4 calories ; 95 % CI= -57.9 , -5.0 ) . Unadjusted analyses yielded similar results ( difference , -32.9 calories ; 95 % CI= -58.9 , -7.0 ) . Compared with the control label , sugar-sweetened beverage health warnings also led to higher intentions to limit sugar-sweetened beverage consumption and elicited more attention , negative emotions , thinking about the harms of sugar-sweetened beverage consumption , and anticipated social interactions . Trial arms did not differ on perceptions of sugar-sweetened beverages ' added sugar content , healthfulness , appeal/coolness , or disease risk . CONCLUSIONS Brief exposure to health warnings reduced sugar-sweetened beverage purchases in this naturalistic RCT . Sugar-sweetened beverage health warning policies could discourage sugar-sweetened beverage consumption . TRIAL REGISTRATION This study is registered at www . clinical trials.gov NCT03511937 CONTEXT Sugar-sweetened beverages like soft drinks and fruit punches contain large amounts of readily absorbable sugars and may contribute to weight gain and an increased risk of type 2 diabetes , but these relationships have been minimally addressed in adults . OBJECTIVE To examine the association between consumption of sugar-sweetened beverages and weight change and  risk of type 2 diabetes in women . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort analyses conducted from 1991 to 1999 among women in the Nurses ' Health Study II . The diabetes analysis included 91,249 women free of diabetes and other major chronic diseases at baseline in 1991 . The weight change analysis included 51,603 women for whom complete dietary information and body weight were ascertained in 1991 , 1995 , and 1999 . We identified 741 incident cases of confirmed type 2 diabetes during 716,300 person-years of follow-up . MAIN OUTCOME MEASURES Weight gain and incidence of type 2 diabetes . RESULTS Those with stable consumption patterns had no difference in weight gain , but weight gain over a 4-year period was highest among women who increased their sugar-sweetened soft drink consumption from 1 or fewer drinks per week to 1 or more drinks per day ( multivariate-adjusted means , 4.69 kg for 1991 to 1995 and 4.20 kg for 1995 to 1999 ) and was smallest among women who decreased their intake ( 1.34 and 0.15 kg for the 2 periods , respectively ) after adjusting for lifestyle and dietary confounders . Increased consumption of fruit punch was also associated with greater weight gain compared with decreased consumption . After adjustment for potential confounders , women consuming 1 or more sugar-sweetened soft drinks per day had a relative risk [ RR ] of type 2 diabetes of 1.83 ( 95 % confidence interval [ CI ] , 1.42 - 2.36 ; P<.001 for trend ) compared with those who consumed less than 1 of these beverages per month . Similarly , consumption of fruit punch was associated with increased diabetes risk ( RR for > or = 1 drink per day compared with < 1 drink per month , 2.00 ; 95 % CI , 1.33 - 3.03 ; P = .001 ) . CONCLUSION Higher consumption of sugar-sweetened beverages is associated with a greater magnitude of weight gain and an increased risk for development of  type 2 diabetes in women , possibly by providing excessive calories and large amounts of rapidly absorbable sugars Xylitol research has been conducted since the early 70 ’s ; at the beginning of 2009 there were almost 500 PubMed - indexed papers on “ xylitol and dental ” . Xylitol research was initiated in Finl and , but nowadays the majority of papers are published by non-Finnish authors . Xylitol studies have been criticized mainly by European research ers . This criticism is reflected for example in the most recent textbook of cariology , Dental Caries – The Disease and its Clinical Management ( 2008 ) , used by students in all Nordic countries . It shows a figure with reduction in caries occurrence in the Turku Sugar Studies as an example , not of the effect of total substitution of dietary sugars with xylitol , but rather “ indicating the importance of removal of sugar from the diet , rather than starch , in caries control “ . Moreover , a frequently cited review in Caries Research in 2004 came to the conclusion that “ there is no evidence for a caries-therapeutic effect of xylitol”.1 Xylitol studies are easy to criticize especially by authors who have never been involved in field trials . For example , to avoid exchange of test products between children of the same class r and omisation has to be done by schools or school classes . This is rarely recognized by the critics of xylitol studies . In addition , it is hard to find volunteers to comply with 2–3 years chewing of a hard and tasteless gum base , which is the control often suggested for chewing gum trials . Polyols like maltitol and sorbitol are by no means inert and are thus not valid controls for xylitol . Fortunately , US dental experts have critically , but positively , conducted research and review ed the literature on xylitol.2–5 One consequence of practical problems associated with field trials is that in systematic review s of methods for caries control and prevention the strict exclusion criteria leave only few xylitol studies for evaluation . For example , the inclusion criteria for a Swedish systematic review on methods of caries prevention ( SBU ; www.sbu.se ) were so strict that hardly any recommendations concerning caries prevention could be made . This also applied to xylitol : according to the report , the evidence on the clinical efficacy for xylitol was inconclusive . In a critical evaluation of the SBU report , the following question was asked “ where does this leave the confused dental practitioner , who has to offer chairside advice to patients , but can not wait of further ( good- quality ) research to be conducted and published , providing a more solid evidence -base ? ” ( Stillman-Lowe , 2005 ) . On the other h and , xylitol has been recommended for use in caries control and prevention by several dental associations . Also the European Food Safety Authority evaluated the literature on xylitol in 2008 and came to the conclusion that “ xylitol chewing gum reduces the risk of caries in children ” . The cl aim had to be reformulated since chewing gum is not a medicine and can thus not be cl aim ed to reduce the risk of a disease , caries . In Europe , there is a strong interest not to give xylitol a better status than for other polyol sweeteners . Xylitol differs from other polyols as is obvious to all experts familiar with microbiology . Xylitol has beneficial effects on the oral flora not shared by other polyols . The evidence so far supports specific xylitol-effects on oral bacteria , but not on saliva .  Xylitol can not be metabolized by plaque bacteria , contrary to sorbitol and other 6-carbon polyols , and may thus favour mineralization . The accumulated evidence suggests that 1 ) mutans streptococci are the target organisms of xylitol in vivo , 2 ) mutans streptococci are reduced and stay on a lower level even during long-term xylitol consumption as long as the consumption lasts , 3 ) xylitol consumption reduces the accumulation of plaque , 4 ) xylitol consumed by mothers reduces the mother-child transmission of mutans streptococci and consequently , caries occurrence in their children,6,7 and 5 ) xylitol consumption reduces the risk of caries in children.4 In clinical trials on xylitol mostly chewing gum with high xylitol concentrations has been used . Studies with low daily doses of xylitol are known as a rule to fail to show any caries-preventive effects . To obtain beneficial xylitol-effects on mutans streptococci , on plaque and caries occurrence xylitol must be consumed three times or more per day , with a daily dose of 5–6 grams.4,7 When using chewing gums or pastilles , saliva stimulation always occurs due to chewing or sucking . Some authors have cl aim ed that the beneficial effects of xylitol are solely based on saliva stimulation and that all sugar-free gums are similar in this respect . In fact , in conditions where caries occurrence is high , even sorbitol gum can prevent caries.8 A recent study elegantly shows caries prevention with xylitol without any saliva stimulation . In this study fifteen-month-old children were given xylitol or sorbitol syrup with a syringe for 12 months.9 The xylitol syrup prevented  early childhood caries  effectively , while sorbitol had no effect . In spite of the abundant literature still more studies are needed on the action of xylitol . Biofilm models could be very useful in xylitol research . There is a clear need for properly design ed , r and omized , controlled , clinical trials to demonstrate 1 ) the feasibility of  xylitol prevention in different population s with different dietary and oral hygiene habits , 2 ) suitable vehicles to deliver xylitol , 3 ) the extent to which xylitol can be “ diluted ” with other polyols without losing the caries preventive effects , and 4 ) the minimum daily xylitol dose and frequency of xylitol are needed to obtain the expected xylitol-effects on mutans streptococci , plaque and most importantly , on caries occurrence . Clinical trials often aim to improve treatment methods . When several clinical trials give similar results , clinicians can be given treatment guidelines based on findings verified by research . In this way research serves the clinicians in treating patients according to evidence -based solid information . Systematic review s are currently required to up date guidelines for caries prevention . As such , critical evaluation of the existing literature is a positive goal , but if it leads to a situation where no treatment guidelines can be given , something is wrong . This also applies to xylitol studies . Though strict inclusion criteria prevent conclusions based on systematic review s of the literature , evidence -based treatment guidelines can still be given for the use of xylitol . Xylitol is a useful adjunct to traditional methods for caries control and prevention . Caries prevention with xylitol has been cl aim ed to be expensive , but if true primary prevention is obtained , as demonstrated in the mother-child study , 6,7 it may be worth it BACKGROUND The consumption of sweetened beverages , refined foods , and pastries has been shown to be associated with an increased risk of  depression  in longitudinal studies . However , any influence that refined carbohydrates has on mood could be commensurate with their proportion in the overall diet ; studies are therefore needed that measure overall intakes of carbohydrate and sugar , glycemic index ( GI ) , and glycemic load . OBJECTIVE We hypothesized that higher dietary GI and glycemic load would be associated with greater odds of the prevalence and incidence of depression . DESIGN This was a prospect i ve cohort study to investigate the relations between dietary GI , glycemic load , and other carbohydrate measures ( added sugars , total sugars , glucose , sucrose , lactose , fructose , starch , carbohydrate ) and depression in postmenopausal women who participated in the Women 's Health Initiative Observational Study at baseline between 1994 and 1998 ( n = 87,618 ) and at the 3-y follow-up ( n = 69,954 ) . RESULTS We found a progressively higher dietary GI to be associated with increasing odds of incident depression in fully adjusted models ( OR for the fifth compared with first quintile : 1.22 ; 95 % CI : 1.09 , 1.37 ) , with the trend being statistically significant ( P = 0.0032 ) . Progressively higher consumption of dietary added sugars was also associated with increasing odds of incident depression ( OR for the fifth compared with first quintile : 1.23 ; 95 % CI : 1.07 , 1.41 ; P-trend = 0.0029 ) . Higher consumption of lactose , fiber , nonjuice fruit , and vegetables was significantly associated with lower odds of incident depression , and nonwhole/refined grain consumption was associated with increased odds of depression . CONCLUSIONS The results from this study suggest that high-GI diets could be a risk factor for depression in postmenopausal women . R and omized trials should be undertaken to examine the question of whether diets rich in low-GI foods could serve as treatments and primary preventive measures for depression in postmenopausal women BACKGROUND Increased energy intake is consistently observed in individuals consuming sugar-sweetened beverages ( SSBs )  , likely mainly because of an inadequate satiety response to liquid calories . However , SSBs have a high content of fructose , the consumption of which acutely fails to trigger responses in key signals involved in energy homeostasis . It is unclear whether the fructose content of SSBs contributes to the increased energy intake in individuals drinking SSBs . OBJECTIVE We investigated whether the relative amounts of fructose and glucose in SSBs modifies ad libitum energy intake over 8 d in healthy adults without fructose malabsorption . DESIGN We conducted 2 r and omized , controlled , double-blind crossover studies to compare the effects of consuming 4 servings/d of a fructose- , glucose- , or aspartame-sweetened beverage  ( study A ; n = 9 )  or a fructose- , glucose- , or high-fructose corn syrup (HFCS)-sweetened beverage  ( study B ; n = 24 ) for 8 d on overall energy intake . SSBs were provided at 25 % of estimated energy requirement , or an equivalent volume of the aspartame-sweetened beverage , and consumption was m and atory . All solid foods were provided at 125 % of estimated energy requirements and were consumed ad libitum . RESULTS In study A , ad libitum energy intake was 120 % ± 10 % , 117 % ± 12 % , and 102 % ± 15 % of estimated energy requirements when subjects consumed the fructose- , glucose- , and aspartame-sweetened beverages . Energy intake was significantly higher in the fructose and glucose phases than in the aspartame phase ( P < 0.003 for each ) , with no difference between the fructose and glucose phases ( P = 0.462 ) . In study B , total energy intake during the fructose , HFCS , and glucose phases was 116 % ± 14 % , 116 % ± 16 % , and 116 % ± 16 % of the subject 's estimated total energy requirements ( P = 0.880 ) . CONCLUSIONS In healthy adults , total 8-d ad libitum energy intake was increased in individuals consuming SSBs compared with aspartame-sweetened beverages . The energy overconsumption observed in individuals consuming SSBs occurred independently of the relative amounts of fructose and glucose in the beverages . These trials were registered at clinical trials.gov as NCT00475475 and NCT01424306 Using a crossover design , eight healthy volunteers r and omly received physiologic amounts ( ⅓ of each subject 's total carbohydrate intake ) of either fructose or sucrose as the primary source of simple sugar , incorporated into isocaloric diets comprised of typical American foods . After 7 and 14 days of consuming either of the two sugars , no change occurred in fasting glucose or insulin levels . In addition , total triglyceride , totalcholesterol , low-density-lipoprotein ( LDL ) cholesterol , and high-density-lipoprotein ( HDL ) cholesterol concentrations were unaltered . Since our study used conventional foods in normal eating patterns rather than contrived formulas or excessive amounts of simple sugar , our data indicate that there is no difference between sucrose or fructose on various lipid components or glucose and fasting insulin levels in the “ real world ” innormal subjects OBJECTIVE The increase in consumption of sugar-added beverages over recent decades may be partly responsible for the obesity epidemic among U.S. adolescents . Our aim was to evaluate the relationship between BMI changes and intakes of sugar-added beverages , milk , fruit juices , and diet soda . RESEARCH METHODS AND PROCEDURES Our prospect i ve cohort study included > 10,000 boys and girls participating in the U.S. Growing Up Today Study . The participants were 9 to 14 years old in 1996 and completed question naires in 1996 , 1997 , and 1998 . We analyzed change in BMI ( kilograms per meter squared ) over two 1-year periods among children who completed annual food frequency question naires assessing typical past year intakes . We studied beverage intakes during the year corresponding to each BMI change , and in separate models , we studied 1-year changes in beverage intakes , adjusting for prior year intakes . Models included all beverages simultaneously ; further models adjusted for total energy intake . RESULTS Consumption of sugar-added beverages was associated with small BMI gains during the corresponding year ( boys : + 0.03 kg/m2 per daily serving , p = 0.04 ; girls : + 0.02 kg/m2 , p = 0.096 ) . In models not assuming a linear dose-response trend , girls who drank 1 serving/d of sugar-added beverages  gained more weight ( + 0.068 , p = 0.02 ) than girls drinking none , as did girls drinking 2 servings/d ( + 0.09 , p = 0.06 ) or 3 + servings/d ( + 0.08 , p = 0.06 ) . Analyses of year-to-year change in beverage intakes provided generally similar findings ; boys who increased consumption of sugar-added beverages from the prior year experienced weight gain ( + 0.04 kg/m2 per additional daily serving , p = 0.01 ) . Children who increased intakes by 2 or more servings/d from the prior year gained weight ( boys : + 0.14 , p = 0.01 ; girls + 0.10 , p = 0.046 ) . Further adjusting our models for total energy intake substantially reduced the estimated effects , which were no longer significant . DISCUSSION Consumption of sugar-added beverages may contribute to weight gain among adolescents , probably due to their contribution to total energy intake , because adjustment for calories greatly attenuated the estimated associations IMPORTANCE Epidemiologic studies have suggested that higher intake of added sugar is associated with cardiovascular disease ( CVD ) risk factors . Few prospect i ve studies have examined the association of added sugar intake with CVD mortality . OBJECTIVE To examine time trends of added sugar consumption as percentage of daily calories in the United States and investigate the association of this consumption with CVD mortality . DESIGN , SETTING , AND PARTICIPANTS National Health and Nutrition Examination Survey ( NHANES , 1988 - 1994 [ III ] , 1999 - 2004 , and 2005 - 2010 [ n = 31,147 ] ) for the time trend analysis and NHANES III Linked Mortality cohort ( 1988 - 2006 [ n = 11 733 ] ) , a prospect i ve cohort of a nationally representative sample of US adults for the association study . MAIN OUTCOMES AND MEASURES Cardiovascular disease mortality . RESULTS Among US adults , the adjusted mean percentage of daily calories from added sugar  increased from 15.7 % ( 95 % CI , 15.0%-16.4 % ) in 1988 - 1994 to 16.8 % ( 16.0%-17.7 % ; P = .02 ) in 1999 - 2004 and decreased to 14.9 % ( 14.2%-15.5 % ; P < .001 ) in 2005 - 2010 . Most adults consumed 10 % or more of calories from added sugar ( 71.4 % ) and approximately 10 % consumed 25 % or more in 2005 - 2010 . During a median follow-up period of 14.6 years , we documented 831 CVD deaths during 163,039 person-years . Age- , sex- , and race/ethnicity-adjusted hazard ratios ( HRs ) of CVD mortality across quintiles of the percentage of daily calories consumed from added sugar were 1.00 ( reference ) , 1.09 ( 95 % CI , 1.05 - 1.13 ) , 1.23 ( 1.12 - 1.34 ) , 1.49 ( 1.24 - 1.78 ) , and 2.43 ( 1.63 - 3.62 ; P < .001 ) , respectively . After additional adjustment for sociodemographic , behavioral , and clinical characteristics , HRs were 1.00 ( reference ) , 1.07 ( 1.02 - 1.12 ) , 1.18 ( 1.06 - 1.31 ) , 1.38 ( 1.11 - 1.70 ) , and 2.03 ( 1.26 - 3.27 ; P = .004 ) , respectively . Adjusted HRs were 1.30 ( 95 % CI , 1.09 - 1.55 ) and 2.75 ( 1.40 - 5.42 ; P = .004 ) , respectively , comparing participants who consumed 10.0 % to 24.9 % or 25.0 % or more calories from added sugar with those who consumed less than 10.0 % of calories from added sugar . These findings were largely consistent across age group , sex , race/ethnicity ( except among non-Hispanic blacks ) , educational attainment , physical activity , health eating index , and body mass index . CONCLUSIONS AND RELEVANCE Most US adults consume more added sugar than is recommended for a healthy diet . We observed a significant relationship between added sugar consumption and increased risk for CVD mortality UNLABELLED Studies on children 's carbohydrate intake , especially fibre intake , and its associations with later health are rare . The current recommendations for fibre intake in children are based on average assumptions and data extrapolated from intakes in adults . Generally , increase in whole-grain consumption and decrease in sucrose intake are considered healthy . Due to fibre 's high bulk volume however , excessive dietary fibre has been feared to decrease energy density have effects on growth , at least in developing countries and in children consuming very restricted diets . Furthermore , it has been speculated that if fats are reduced from the diet , it may become high in sucrose . In STRIP study , which is a long-term , r and omized controlled trial design ed to decrease the exposure of children to known risk factors of atherosclerosis , carbohydrate intakes have been investigated in detail in children aged 13 months to 9 years . The intervention was successful in decreasing saturated fat intake and cholesterol concentrations throughout childhood and adolescence . The study results also show that a higher than average fibre intake does not displace energy or disturb growth in children and that children with high fibre intake have better dietary quality than those with low fibre intake .  Dietary fibre  intake associated with lower serum total cholesterol concentrations whereas increases in total carbohydrate , sucrose and fructose intakes associated with increases in serum triglyceride concentrations . In conclusion , from the point of view of CHD risk factor prevention , efforts aim ing at increasing the fibre intake while restricting that of refined sugar seem justified in the child population in developed countries . CLINICAL TRIAL REGISTRATION INFORMATION NCT00223600 BACKGROUND About 9 % of average dietary energy intake in the United States comes from fructose . Such a high consumption raises concern about the metabolic effects of this sugar . OBJECTIVE The objective of this study was to determine the effect of dietary fructose on plasma lipids . DESIGN The study was conducted in the General Clinical Research Center at Fairview-University of Minnesota Medical Center . The participants were 24 healthy adult volunteers ( 12 men and 12 women ; 6 of each sex were aged < 40 y and 6 of each sex were aged > /=40 y ) . All subjects received 2 isoenergetic study diets assigned by using a r and omized , balanced crossover design . One diet provided 17 % of energy as fructose . The other diet was sweetened with glucose and was nearly devoid of fructose . Each diet was fed for 6 wk . Both diets were composed of common foods and contained nearly identical amounts of carbohydrate , protein , fat , fiber , cholesterol , and saturated , monounsaturated , and polyunsaturated fatty acids . All meals were prepared in the metabolic kitchen of the General Clinical Research Center . RESULTS The responses to the study diets differed by sex . In men , the fructose diet produced significantly higher fasting , postpr and ial , and daylong plasma triacylglycerol concentrations than did the glucose diet . The daylong plasma triacylglycerol concentration after 6 wk of the fructose diet was 32 % greater in men than the corresponding concentration during the glucose diet ( P : < 0.001 ) . The fructose diet had no significant effect on fasting or postpr and ial plasma triacylglycerol concentrations in women . The fructose diet also had no persistent effect on fasting plasma cholesterol , HDL cholesterol , or LDL cholesterol in either men or women . CONCLUSIONS Dietary fructose was associated with increased fasting and postpr and ial plasma triacylglycerol concentrations in men . Diets high in added fructose may be undesirable , particularly for men . Glucose may be a suitable replacement sugar
Data from these sources do not support linkages between sugar consumption at normal levels within the human diet and various adverse metabolic and health-related effects
Abstract The relationship between sugar consumption and various health-related sequelas is controversial .
Some investigators have argued that excessive sugar consumption is associated with increased risk of obesity , coronary heart disease , diabetes ( T2D ) , metabolic syndrome , non-alcoholic fatty liver disease , and stimulation of reward pathways in the brain potentially causing excessive caloric consumption .
These concerns have influenced organizations such as the World Health Organization , the Scientific Advisory Committee on Nutrition in Engl and not to exceed 5 % of total energy and the Dietary Guidelines for Americans Advisory Committee 2015 to recommend upper limits of sugar consumption not to exceed 10 % of calories .
Data from many r and omized control trials ( RCTs ) do not support linkages between sugar consumption at normal levels within the human diet and various adverse metabolic and health-related effects .
Fructose and glucose are typically consumed together in roughly equal proportions from high-fructose corn syrup ( also known as isoglucose in Europe ) or sucrose .
The purpose of this review is to present data from recent RCTs and findings from recent systematic review s and meta-analyses related to sugar consumption and its putative health effects .
This review evaluates findings from recent r and omized controlled trials , systematic review s and meta-analyses into the relationship of sugar consumption and a range of health-related issues including energy-regulating hormones , obesity , cardiovascular disease , diabetes , and accumulation of liver fat and neurologic responses .