Low- and no-calorie sweetened beverages seem a safe replacement for sugar-sweetened beverages: A meta-analysis

Sugar consumption has emerged as an important public health concern. The evidence on this concern derives largely from consumption of sugar-sweetened beverages (SSBs), with excess intake of SSBs associated with weight gain and downstream cardiometabolic complications. However, it is unclear whether low- and no-calorie sweetened beverages (LNCSBs) as a replacement strategy for SSBs provide the intended benefits. Data from prospective cohort studies suggests associations between LNCSBs and a higher risk of the conditions that they are intended to prevent, such as weight gain, diabetes, and cardiovascular disease. Biological mechanisms involving impaired sensory and endocrine signaling that was mediated by the sweet taste receptor and changes to the microbiome have been implicated in support of these observations. However, there are methodological considerations limiting the inferences that can be drawn from these data, because available prospective cohort studies are at high risk for reverse causality.

On March 14, 2022 a new systematic review and meta-analysis exploring associations of LNCSBs as a replacement for SSB with body weight and cardiometabolic risk was published in JAMA Netw Open. This systematic review and network meta-analysis was conducted according to the Cochrane Handbook for Systematic Reviews of Interventions and included randomized clinical trials (RCTs) with at least 2 weeks of interventions comparing LNCSBs, SSBs, and/or water. A total of 17 RCTs with 24 trial comparisons were included, involving 1733 adults (mean [SD] age, 33.1 [6.6] years; 1341 women [77.4%]) with overweight or obesity who were at risk for or had diabetes. Overall, LNCSBs were a substitute for SSBs in 12 RCTs (n = 601 participants), water was a substitute for SSBs in 3 RCTs (n = 429), and LNCSBs were a substitute for water in 9 RCTs (n = 974). Substitution of LNCSBs for SSBs was associated with reduced body weight (mean difference [MD], −1.06 kg; 95% CI, −1.71 to –0.41 kg), body mass index (MD, −0.32; 95% CI, −0.58 to –0.07), percentage of body fat (MD, −0.60%; 95% CI, −1.03% to –0.18%), and intrahepatocellular lipid (standardized mean difference, −0.42; 95% CI, −0.70 to –0.14). Substituting water for SSBs was not associated with any outcome. There was also no association found between substituting LNCSBs for water with any outcome except glycated hemoglobin A1c (MD, 0.21%; 95% CI, 0.02% to 0.40%) and systolic blood pressure (MD, −2.63 mm Hg; 95% CI, −4.71 to −0.55 mm Hg).

That is, these data suggest that over the moderate term, LNCSBs are a viable alternative to water as a replacement strategy in adults with overweight or obesity who are at risk for or have diabetes.


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