Consumption of Beverages Containing Low-Calorie Sweeteners, Diet, and Cardiometabolic Health in Youth With Type 2 Diabetes

      Abstract

      Background

      Low-calorie sweetened beverages (LCSBs) are commonly used as a lower-calorie alternative to sugar-sweetened beverages (SSBs) by individuals with type 2 diabetes. However, little is known about how intake of LCSBs is related to dietary intake and cardiometabolic health, particularly among youth.

      Objective

      To test the hypothesis that having higher baseline LCSB intake and increasing LCSB intake over 2 years of follow-up are associated with poorer dietary intake and higher cardiometabolic risk factors among youth enrolled in the Treatment Option for Type 2 Diabetes in Adolescents and Youth (TODAY) study.

      Design

      Secondary, exploratory, analysis of baseline and longitudinal data from the TODAY study, which was a randomized, multisite trial conducted from 2004 to 2012, to compare effects of 3 interventions (metformin alone, metformin + rosiglitazone, and metformin + intensive lifestyle intervention) on glycemic control in youth with type 2 diabetes.

      Participants/setting

      The study included 476 children and adolescents (10-17 years, mean body mass index 34.9 ± 7.8 kg/m2), who were participants in the multicenter (n = 15) TODAY study.

      Main outcome measures

      Diet was assessed using a food frequency questionnaire. Differences in energy intake, macronutrients, food group intakes, and cardiometabolic biomarkers were evaluated in 3 groups of LCSB consumers at baseline (low [1-4 servings/wk], medium [5-11 servings/wk], and high [≥12 servings/wk]), each compared with nonconsumers, and between 4 groups of change in LCSB intake (nonconsumption at start of study and nonconsumption after 2 years, increase in consumption after 2 years, decrease in consumption after 2 years, and high consumption at start of study and high consumption after 2 years).

      Statistical analyses performed

      Multivariable linear regression was performed at baseline and longitudinally over 2 years of follow-up.

      Results

      Energy (kilocalories), fiber, carbohydrate, total fat, saturated fat, and protein intake (grams) were higher among high LCSB consumers compared with nonconsumers at baseline. No associations were observed between LCSB consumption and cardiometabolic risk factors at baseline. Change in LCSB intake between baseline and follow-up was not associated with change in energy intake or cardiometabolic risk factors. Participants who decreased LCSB consumption reported greater increases in sugar intake (18.4 ± 4.8 g) compared with those who increased LCSB consumption (5.7 ± 4.9 g) or remained high LCSB consumers (5.9 ± 7.4 g), but this trend was not statistically significant after a correction for multiple testing.

      Conclusions

      LCSB consumption was associated with higher energy intake in youth with type 2 diabetes, with the highest energy intakes reported in high LCSB consumers. Those who reduced LCSB consumption tended to report greater increases in sugar intake during follow-up, but further studies are needed to better understand this trend.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of the Academy of Nutrition and Dietetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Sylvetsky A.C.
        • Jin Y.
        • Clark E.J.
        • Welsh J.A.
        • Rother K.I.
        • Talegawkar S.A.
        Consumption of low-calorie sweeteners among children and adults in the United States.
        J Acad Nutr Diet. 2017; 117: 441-448.e442
        • Sylvetsky A.C.
        • Welsh J.A.
        • Brown R.J.
        • Vos M.B.
        Low-calorie sweetener consumption is increasing in the United States.
        Am J Clin Nutr. 2012; 96: 640-646
        • Azad M.B.
        • Abou-Setta A.M.
        • Chauhan B.F.
        • et al.
        Nonnutritive sweeteners and cardiometabolic health: A systematic review and meta-analysis of randomized controlled trials and prospective cohort studies.
        CMAJ. 2017; 189: E929-E939
        • Sylvetsky A.C.
        • Rother K.I.
        Nonnutritive sweeteners in weight management and chronic disease: A review.
        Obesity (Silver Spring). 2018; 26: 635-640
        • Johnson R.K.
        • Lichtenstein A.H.
        • Anderon A.M.
        • et al.
        Low-calorie sweetened beverages and cardiometabolic health: A science advisory from the American Heart Association.
        Circulation. 2018; 138
        • Fowler S.P.
        • Williams K.
        • Resendez R.G.
        • Hunt K.J.
        • Hazuda H.P.
        • Stern M.P.
        Fueling the obesity epidemic? Artificially sweetened beverage use and long-term weight gain.
        Obesity (Silver Spring). 2008; 16: 1894-1900
        • Forshee R.A.
        • Storey M.L.
        Total beverage consumption and beverage choices among children and adolescents.
        Int J Food Sci Nutr. 2003; 54: 297-307
        • O’Connor L.
        • Imamura F.
        • Lentjes M.
        • Khaw K.
        • Wareham N.
        • Forouhi N.
        Prospective associations and population impact of sweet beverage intake and type 2 diabetes, and effects of substitutions with alternative beverages.
        Diabetologia. 2015; 58: 1474-1483
        • Lutsey P.L.
        • Steffen L.M.
        • Stevens J.
        Dietary intake and the development of the metabolic syndrome: The Atherosclerosis Risk in Communities study.
        Circulation. 2008; 117: 754-761
        • Nettleton J.A.
        • Lutsey P.L.
        • Wang Y.
        • Lima J.A.
        • Michos E.D.
        • Jacobs Jr., D.R.
        Diet soda intake and risk of incident metabolic syndrome and type 2 diabetes in the Multi-Ethnic Study of Atherosclerosis (MESA).
        Diabetes Care. 2009; 32: 688-694
        • Young J.
        • Conway E.M.
        • Rother K.I.
        • Sylvetsky A.C.
        Low-calorie sweetener use, weight, and metabolic health among children: A mini-review.
        Pediatr Obes. 2019; 14e12521
        • Rogers P.J.
        • Hogenkamp P.S.
        • de Graaf C.
        • et al.
        Does low-energy sweetener consumption affect energy intake and body weight? A systematic review, including meta-analyses, of the evidence from human and animal studies.
        Int J Obes (Lond). 2016; 40: 381-394
        • de Ruyter J.C.
        • Olthof M.R.
        • Seidell J.C.
        • Katan M.B.
        A trial of sugar-free or sugar-sweetened beverages and body weight in children.
        N Engl J Med. 2012; 367: 1397-1406
        • Ebbeling C.B.
        • Feldman H.A.
        • Chomitz V.R.
        • et al.
        A randomized trial of sugar-sweetened beverages and adolescent body weight.
        N Engl J Med. 2012; 367: 1407-1416
        • Maersk M.
        • Belza A.
        • Stodkilde-Jorgensen H.
        • et al.
        Sucrose-sweetened beverages increase fat storage in the liver, muscle, and visceral fat depot: A 6-mo randomized intervention study.
        Am J Clin Nutr. 2012; 95: 283-289
        • Madjd A.
        • Taylor M.A.
        • Delavari A.
        • Malekzadeh R.
        • Macdonald I.A.
        • Farshchi H.R.
        Beneficial effects of replacing diet beverages with water on type 2 diabetic obese women following a hypo-energetic diet: A randomized, 24-week clinical trial.
        Diabetes Obes Metab. 2017; 19: 125-132
        • Bleich S.N.
        • Wolfson J.A.
        • Vine S.
        • Wang Y.C.
        Diet-beverage consumption and caloric intake among US adults, overall and by body weight.
        Am J Public Health. 2014; 104: e72-e78
        • Drewnowski A.
        • Rehm C.D.
        Consumption of low-calorie sweeteners among U.S. adults is associated with higher Healthy Eating Index (HEI 2005) scores and more physical activity.
        Nutrients. 2014; 6: 4389-4403
        • An R.
        Beverage consumption in relation to discretionary food intake and diet quality among US adults, 2003 to 2012.
        J Acad Nutr Diet. 2016; 116: 28-37
        • Binkley J.
        • Golub A.
        Comparison of grocery purchase patterns of diet soda buyers to those of regular soda buyers.
        Appetite. 2007; 49: 561-571
        • Leahy M.
        • Ratliff J.C.
        • Riedt C.S.
        • Fulgoni V.L.
        Consumption of low-calorie sweetened beverages compared to water is associated with reduced intake of carbohydrates and sugar, with no adverse relationships to glycemic responses: Results from the 2001-2012 National Health and Nutrition Examination Surveys.
        Nutrients. 2017; 9: 928
        • Malek A.M.
        • Hunt K.J.
        • DellaValle D.M.
        • Greenberg D.
        • St Peter J.V.
        • Marriott B.P.
        Reported consumption of low-calorie sweetener in foods, beverages, and food and beverage additions by US adults: NHANES 2007-2012.
        Curr Dev Nutr. 2018; 2: nzy054
        • Sigman-Grant M.J.
        • Hsieh G.
        Reported use of reduced-sugar foods and beverages reflect high-quality diets.
        J Food Sci. 2005; 70: S42-S46
        • Gibson S.A.
        • Horgan G.W.
        • Francis L.E.
        • Gibson A.A.
        • Stephen A.M.
        Low calorie beverage consumption is associated with energy and nutrient intakes and diet quality in British adults.
        Nutrients. 2016; 8: 9
        • Piernas C.
        • Tate D.F.
        • Wang X.
        • Popkin B.M.
        Does diet-beverage intake affect dietary consumption patterns? Results from the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial.
        Am J Clin Nutr. 2013; 97: 604-611
        • Group T.S.
        Design of a family-based lifestyle intervention for youth with type 2 diabetes: the TODAY study.
        Int J Obes (Lond). 2010; 34: 217-226
        • Kriska A.
        • El Ghormli L.
        • Copeland K.C.
        • et al.
        Impact of lifestyle behavior change on glycemic control in youth with type 2 diabetes.
        Pediatr Diabetes. 2018; 19: 36-44
        • Group T.S.
        Lipid and inflammatory cardiovascular risk worsens over 3 years in youth with type 2 diabetes: The TODAY clinical trial.
        Diabetes Care. 2013; 36: 1758-1764
        • Zeitler P.
        • Epstein L.
        • et al.
        • TODAY Study Group
        Treatment options for type 2 diabetes in adolescents and youth: A study of the comparative efficacy of metformin alone or in combination with rosiglitazone or lifestyle intervention in adolescents with type 2 diabetes.
        Pediatr Diabetes. 2007; 8: 74-87
        • Mayer-Davis E.J.
        • Nichols M.
        • Liese A.D.
        • et al.
        Dietary intake among youth with diabetes: The SEARCH for Diabetes in Youth Study.
        J Am Diet Assoc. 2006; 106: 689-697
      1. NutritionQuest. Assessment & analytic services: Questionnaires and screeners.
        (Published 2014. Accessed June 2019)
        • Cullen K.W.
        • Watson K.
        • Zakeri I.
        Relative reliability and validity of the Block Kids Questionnaire among youth aged 10 to 17 years.
        J Am Diet Assoc. 2008; 108: 862-866
        • Delahanty L.
        • Kriska A.
        • Edelstein S.
        • et al.
        Self-reported dietary intake of youth with recent onset of type 2 diabetes: Results from the TODAY study.
        J Acad Nutr Diet. 2013; 113: 431-439
      2. Nutrition Coordinating Center. Regents of the University of Minnesota. NDSR Software.
        (Published 2019. Accessed June 2019)
      3. US Department of Agriculture Center for Nutrition Policy and Promotion. The Food Guide Pyramid.
        Home and Garden Bulletin. 2000; 252
        • Sylvetsky A.C.
        • Rother K.I.
        Trends in the consumption of low-calorie sweeteners.
        Physiol Behav. 2016; 164: 446-450
        • Watson E.
        PepsiCo ditches aspartame from Diet Pepsi in US: “While decades of studies show aspartame is safe, we recognize that consumer demand is evolving.”.
        (Published 2017. Accessed May 2019)
        • Weston A.T.
        • Petosa R.
        • Pate R.R.
        Validation of an instrument for measurement of physical activity in youth.
        Med Sci Sports Exerc. 1997; 29: 138-143
      4. SAS Institute Inc. Version 9.4 of SAS System for Windows (Release 9.4). Cary, NC; 2011.

        • Sylvetsky A.C.
        • Figueroa J.
        • Zimmerman T.
        • Swithers S.E.
        • Welsh J.A.
        Consumption of low-calorie sweetened beverages is associated with higher total energy and sugar intake among children, NHANES 2011-2016.
        Pediatr Obes. 2019; 14: e12535
        • Baker-Smith C.M.
        • de Ferranti S.D.
        • Cochran W.J.
        • Committee On Nutrition, Section on Gastroenterology, Hepatology, and Nutrition
        The use of nonnutritive sweeteners in children.
        Pediatrics. 2019; 144: e20192765
        • Sylvetsky A.C.
        • Brown R.J.
        • Blau J.E.
        • Walter M.
        • Rother K.I.
        Hormonal responses to non-nutritive sweeteners in water and diet soda.
        Nutr Metab (Lond). 2016; 13: 71
        • Pepino M.Y.
        • Tiemann C.D.
        • Patterson B.W.
        • Wice B.M.
        • Klein S.
        Sucralose affects glycemic and hormonal responses to an oral glucose load.
        Diabetes Care. 2013; 36: 2530-2535
        • Swithers S.E.
        • Davidson T.L.
        A role for sweet taste: Calorie predictive relations in energy regulation by rats.
        Behav Neurosci. 2008; 122: 161-173
        • Brown R.J.
        • de Banate M.A.
        • Rother K.I.
        Artificial sweeteners: A systematic review of metabolic effects in youth.
        Int J Pediatr Obes. 2010; 5: 305-312
        • Visek A.J.
        • Blake E.F.
        • Otterbein M.
        • Chandran A.
        • Sylvetsky A.C.
        Sweet maps: A conceptualization of low-calorie sweetener consumption among young adults.
        Curr Dev Nutr. 2019; 3: nzy103
        • Sylvetsky A.C.
        • Conway E.M.
        • Malhotra S.
        • Rother K.I.
        Development of sweet taste perception: Implications for artificial sweetener use.
        Endocr Dev. 2017; 32: 87-99
        • Zhang G.H.
        • Chen M.L.
        • Liu S.S.
        • et al.
        Effects of mother’s dietary exposure to acesulfame-K in pregnancy or lactation on the adult offspring's sweet preference.
        Chem Senses. 2011; 36: 763-770
        • Appleton K.M.
        • Tuorila H.
        • Bertenshaw E.J.
        • de Graaf C.
        • Mela D.J.
        Sweet taste exposure and the subsequent acceptance and preference for sweet taste in the diet: Systematic review of the published literature.
        Am J Clin Nutr. 2018; 107: 405-419
        • Trabulsi J.
        • Schoeller D.A.
        Evaluation of dietary assessment instruments against doubly labeled water, a biomarker of habitual energy intake.
        Am J Physiol Endocrinol Metab. 2001; 281: E891-E899

      Biography

      A. C. Sylvetsky is an assistant professor, Department of Exercise and Nutrition Sciences, and affiliated faculty, Sumner M. Redstone Global Center for Prevention and Wellness, Milken Institute School of Public Health, The George Washington University, Washington, DC.

      Biography

      S. A. Talegawkar is an associate professor, Department of Exercise and Nutrition Sciences; Milken Institute School of Public Health, The George Washington University, Washington, DC.

      Biography

      A. Chandran is a research associate, Department of Exercise and Nutrition Sciences, Milken Institute School of Public Health, The George Washington University, Washington, DC; and a postdoctoral fellow, Matthew Gfeller Sport-Related TBI Research Center, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill.

      Biography

      J. A. Welsh is an assistant professor, Department of Pediatrics, Emory University School of Medicine, Emory University, Atlanta, GA.

      Biography

      K. Drews is an associate research professor, George Washington University Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD.

      Biography

      L. El ghormli is a data scientist, George Washington University Biostatistics Center, Milken Institute School of Public Health, The George Washington University, Rockville, MD.