Personal View
Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses

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Summary

Evidence suggests that excessive intake of added sugars has adverse effects on cardiometabolic health, which is consistent with many reviews and consensus reports from WHO and other unbiased sources. 74% of products in the US food supply contain caloric or low-calorie sweeteners, or both. Of all packaged foods and beverages purchased by a nationally representative sample of US households in 2013, 68% (by proportion of calories) contain caloric sweeteners and 2% contain low-calorie sweeteners. We believe that in the absence of intervention, the rest of the world will move towards this pervasiveness of added sugars in the food supply. Our analysis of trends in sales of sugar-sweetened beverages around the world, in terms of calories sold per person per day and volume sold per person per day, shows that the four regions with the highest consumption are North America, Latin America, Australasia, and western Europe. The fastest absolute growth in sales of sugar-sweetened beverages by country in 2009–14 was seen in Chile. We believe that action is needed to tackle the high levels and continuing growth in sales of such beverages worldwide. Many governments have initiated actions to reduce consumption of sugar-sweetened beverages in the past few years, including taxation (eg, in Mexico); reduction of their availability in schools; restrictions on marketing of sugary foods to children; public awareness campaigns; and positive and negative front-of-pack labelling. In our opinion, evidence of the effectiveness of these actions shows that they are moving in the right direction, but governments should view them as a learning process and improve their design over time. A key challenge for policy makers and researchers is the absence of a consensus on the relation of beverages containing low-calorie sweeteners and fruit juices with cardiometabolic outcomes, since decisions about whether these are healthy substitutes for sugar-sweetened beverages are an integral part of policy design.

Introduction

Over the past several decades, the world has become increasingly aware of the role of added sugars, particularly in beverages, as a major driver of increased weight gain and diabetes. This problem is especially evident in high-income countries such as the USA, the UK, and Australia, where consumption of sugar-sweetened beverages increased throughout the 20th century.1, 2, 3, 4, 5

In this Personal View, we briefly discuss the role of caloric sweeteners (also known as nutritive sweeteners) and low-calorie sweeteners (also known as non-nutritive sweeteners) in weight gain, diabetes, and other cardiometabolic health problems. We then provide an update, based on a new dataset, of global trends in sales of beverages containing caloric and low-calorie sweeteners, with a focus on understudied countries outside North America, Europe, and Australasia. We group sugar-sweetened beverages into three categories: caloric soft drinks, fruit drinks, and sports and energy drinks. To illustrate anticipated global trends in the next decade, we also provide an in-depth analysis of trends for added caloric sweeteners and low-calorie sweeteners in both foods and beverages in the USA. We end with a review of the policy responses that have been put into place around the world.

Section snippets

Cardiometabolic effects of caloric and low-calorie sweeteners

The past 25 years have seen a revolution in our understanding of the effect of caloric sweeteners (including sugar) on energy intake, obesity, and diabetes. Although the relation between sugar and insulin control has been understood since the 1920s,6 appeals to view sugar as a danger to health were ignored by most of the health profession during the 1950s and 1960s.7, 8 Public health and biomedical scholars' focus on sugar-sweetened beverages increased substantially after groundbreaking work by

Caloric and low-calorie sweeteners in the US food supply

The USA has one of the world's most complex food supplies in terms of the number of products with unique ingredients; however, our research and that of others show that this modern supermarket-based system is growing rapidly in most low-income and middle-income countries. Thus, study of the US food supply can help to illustrate global trends—eg, the extent to which sweeteners are added in packaged foods and beverages.70, 71, 72, 73, 74 We analysed data from the Nielsen Homescan Services

Trends in beverage sales

We used data for global trends in beverage sales from the Euromonitor Passport International database,78, 79 which has been used in other studies of sugar-sweetened beverages.80 Our definition of sugar-sweetened beverages included caloric soft drinks (carbonated and non-carbonated), fruit drinks (sweetened beverages of diluted fruit juice and often other caloric sweeteners and flavourings), and several fast-growing categories—namely, energy drinks, sports drinks, and sugar-sweetened (often

Global overview

In view of the adverse health effects associated with the widespread consumption of sugar-sweetened beverages, many national governments have taken action to reduce consumption.26, 83 We identified such policies from the World Cancer Research Fund (WCRF) International NOURISHING database.84, 85 Actions led by the private sector were not included. This database does not represent a comprehensive global survey, so our review of existing policy actions was selective. We identified the most common

Conclusion

The evidence presented in this Personal View has four important policy implications. First, evidence that added sugars have adverse effects on weight gain and many cardiometabolic risks provides a rationale for government action. Sugar-sweetened beverages and processed food are major sources of added sugars in most countries. WHO has recommended the amount of added sugars be reduced in foods, but the evidence for the effectiveness of this recommendation is less clear than for that for

Search strategy and selection criteria

We searched for publications on MEDLINE from Jan 1, 2000, to March 31, 2015. We did a selective review of published work on the effect of foods and beverages with added caloric sweeteners and low-calorie sweeteners on cardiometabolic outcomes, from the perspective of the evidence needed to inform policy, referencing key studies and the emergence of the evidence base over time to provide an up-to-date picture. This is not a systematic review but a Personal View in which we cite selected key

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