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