Recent studies using data from the National Health and Nutrition Examination Survey (NHANES) have used inconsistent approaches to identify and categorize beverages, especially those containing low-calorie sweeteners (LCS), also referred to as low-calorie sweetened beverages (LCSBs). Herein, we investigate the approaches used to identify and categorize LCSBs in recent analyses of NHANES data. We reviewed published studies examining LCS consumption in relation to dietary and health outcomes and extracted the methods used to categorize LCS as reported by the authors of each study. We then examined the extent to which these approaches reliably identified LCSBs using the Internet Archive Wayback Machine to examine beverage ingredients lists across three NHANES cycles (2011–2016). None of the four general strategies used appeared to include all LCSBs while also excluding all beverages that did not contain LCS. In some cases, the type of sweetener in the beverage consumed could not be clearly determined; we found 9, 16, and 18 of such “mixed” beverage identifiers in the periods 2011–2012, 2013–2014, and 2015–2016, respectively. Then, to illustrate how heterogeneity in beverage categorization may impact the outcomes of published analyses, we compared results of a previously published analysis with outcomes when “mixed” beverages were grouped either all as LCSBs or all as sugary beverages. Our results suggest that caution is warranted in design and interpretation of studies using NHANES data to examine dietary and health correlates of sweetened beverage intake.

Nonalcoholic fatty liver disease (NAFLD) is now thought to be the most common liver disease worldwide. Cardiovascular complications are a leading cause of mortality in NAFLD. Fructose, a common nutrient in the westernized diet, has been reported to be associated with increased cardiovascular risk, but its impact on adolescents with NAFLD is not well understood. We designed a 4-week randomized, controlled, double-blinded beverage intervention study. Twenty-four overweight Hispanic-American adolescents who had hepatic fat >8% on imaging and who were regular consumers of sweet beverages were enrolled and randomized to calorie-matched study-provided fructose only or glucose only beverages. After 4 weeks, there was no significant change in hepatic fat or body weight in either group. In the glucose beverage group there was significantly improved adipose insulin sensitivity, high sensitivity C-reactive protein (hs-CRP), and low-density lipoprotein (LDL) oxidation. These findings demonstrate that reduction of fructose improves several important factors related to cardiovascular disease despite a lack of measurable improvement in hepatic steatosis. Reducing dietary fructose may be an effective intervention to blunt atherosclerosis progression among NAFLD patients and should be evaluated in longer term clinical trials.

Background: This study aims to describe patterns of truncal versus peripheral fat deposition measured by truncal-to-leg fat ratio (TLR) in adolescents and examine associations of TLR with cardiometabolic (CMD) risk factors. Methods: Data were from 3810 adolescents (12-19 years old) in the National Health and Examination Survey (NHANES) 2003-2006. Body fat was assessed by dual-energy X-ray absorptiometry, and CMD risk factors were determined by blood samples and physical examination. Linear and logistic regressions adjusted for BMI z-score and other covariates were used to examine associations of TLR with CMD risk factors as continuous and dichotomized outcomes, respectively. Results: Adolescents who were Mexican American, who have lower income, and with obesity had the highest mean TLR (all p < 0.05). In linear regression, increasing TLR was associated positively with homeostasis model assessment of insulin resistance (HOMA-IR), triglycerides, total cholesterol, systolic blood pressure (BP), c-reactive protein, and alanine aminotransferase (ALT), and negatively with high-density lipoprotein (HDL) cholesterol in both sexes (p < 0.05). TLR was also associated with diastolic BP in boys and low-density lipoprotein cholesterol in girls (p < 0.05). A similar pattern of findings resulted from logistic regression. When further stratified by race/ethnicity, TLR was positively associated with high triglycerides, total cholesterol, and ALT for White and/or Mexican American (p < 0.05), but not Black adolescents, while associations with HOMA-IR and HDL were significant for all race/ethnicities. Conclusions: In this cohort of adolescents, TLR was associated with several risk factors independent of BMI z-score, although some findings were sex or race/ethnicity specific. Body fat distribution may be an important determinant of future CMD.

Objective: The Healthy Weight Counseling Maintenance of Certification (MOC) program integrates pediatrician training and clinic changes to promote use of evidence-based, diet and physical activity (PA) health messages and counseling strategies. This interrupted time series study assessed the impact of this MOC program on provision of weight-related counseling. Methods: We randomly selected 10–15 well-child visit charts at three time points before and three time points after 102 Georgia pediatricians began the MOC in 2012–2015. Linear binomial regression compared the frequency of behavior-change goal setting and health messaging documentation (fruit/vegetable consumption, sugar-sweetened beverage consumption, out-of-home food consumption, PA, and screen time) before and after MOC participation. Results: At baseline, pediatricians documented behavior-change goals with 44% of patients, with an additional 49% of patients having documented goals after their pediatrician started the MOC (99.5% confidence interval [CI]: 21–77%). Similarly, absolute increases in the proportion of patients with documentation for sugar-sweetened beverage consumption (adjusted prevalence difference [aPD]: 37%; 99.5% CI: 13–62%) and out-of-home eating were observed (aPD: 38%; 99.5% CI: 12–64%). Conclusion: The Healthy Weight Counseling MOC is associated with increased and sustained use of evidence-based health messages and counseling strategies. Practice implications: Continuing education and facilitation of system changes help improve physicians’ weight-related counseling.

Background- Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. Methods and Results- In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey (NHANES) 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated by added sugar consumption level (<10%, 10 to <15%, 15 to <20%, 20 to <25%, 25 to <30%, and 30% of total energy). Multivariable means were weighted to be representative of US adolescents and variances adjusted for the complex sampling methods. Daily consumption of added sugars averaged 21.4% of total energy. Added sugars intake was inversely correlated with mean high-density lipoprotein cholesterol levels (mmol/L) which were 1.40 (95% confidence interval [CI] 1.36 to 1.44) among the lowest consumers and 1.28 (95% CI 1.23 to 1.33) among the highest (P trend =0.001). Added sugars were positively correlated with low-density lipoproteins (P trend =0.01) and geometric mean triglycerides (P trend =0.05). Among the lowest and highest consumers, respectively, low-density lipoproteins (mmol/L) were 2.24 (95% CI 2.12 to 2.37) and 2.44 (95% CI 2.34 to 2.53), and triglycerides (mmol/L) were 0.81 (95% CI 0.74, 0.88) and 0.89 (95% CI 0.83 to 0.96). Among those overweight/obese (85th percentile body-mass-index), added sugars were positively correlated with the homeostasis model assessment (P linear trend =0.004). Conclusion- Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.

Objectives: To assess the impact of Power Up for 30, a flexible, Comprehensive School Physical Activity Program-based state-wide elementary school initiative, on school physical activity opportunities (physical education, recess, in-class physical activity, before-school physical activity, and after-school physical activity) one year after Power Up for 30 training. Design: Quasi-experimental. Methods: In 2013, all 1333 public Georgia elementary schools were invited to complete the School Physical Activity Survey which assessed school physical activity opportunities. Upon survey completion, schools were invited to attend training. Of the 719 (54%) schools meeting survey response criteria, 300 schools attended training by 9/2014 and 419 schools did not. Between 3/2015–5/2015, 79 trained and 80 untrained schools were randomly selected to receive a follow-up survey assessing the frequency and duration of physical activity opportunities. Analyses, adjusted for baseline physical activity opportunities and school characteristics, compared weekly minutes of physical activity opportunities at follow-up between trained and untrained schools. Results: In adjusted analyses at follow-up, trained schools provided 36 more minutes of weekly physical activity opportunities than untrained schools (99% confidence interval: 16–56), particularly during recess (mean difference: 8 min per week; 99% confidence interval: 0–17), during in-class breaks (mean difference: 11 min per week, 99% confidence interval: 3–20), and before school (mean difference: 8 min per week, 99% confidence interval: 4–12). Conclusions: Flexible, multi-component interventions like Power Up for 30 increase physical activity opportunities. If future studies identify that school physical activity opportunities positively impact student physical activity, this model may be a feasible strategy for broad-scale implementation.

Calories from any food have the potential to increase risk for obesity and cardiometabolic disease because all calories can directly contribute to positive energy balance and fat gain. However, various dietary components or patterns may promote obesity and cardiometabolic disease by additional mechanisms that are not mediated solely by caloric content. Researchers explored this topic at the 2017 CrossFit Foundation Academic Conference ‘Diet and Cardiometabolic Health – Beyond Calories’, and this paper summarizes the presentations and follow-up discussions. Regarding the health effects of dietary fat, sugar and non-nutritive sweeteners, it is concluded that food-specific saturated fatty acids and sugar-sweetened beverages promote cardiometabolic diseases by mechanisms that are additional to their contribution of calories to positive energy balance and that aspartame does not promote weight gain. The challenges involved in conducting and interpreting clinical nutritional research, which preclude more extensive conclusions, are detailed. Emerging research is presented exploring the possibility that responses to certain dietary components/patterns are influenced by the metabolic status, developmental period or genotype of the individual; by the responsiveness of brain regions associated with reward to food cues; or by the microbiome. More research regarding these potential ‘beyond calories’ mechanisms may lead to new strategies for attenuating the obesity crisis.

Background: Low-calorie and no-calorie sweeteners (LCSs) have emerged as alternatives to added sugars. Research suggests that consumption among all Americans is increasing, yet it is unknown whether consumption trends differ among population subgroups. Objective: Our study aimed to assess recent national trends in LCS consumption among children and other demographic subgroups in the United States. Design: We used NHANES data collected in five 2-y cycles from 1999–2000 to 2007–2008. Consumption of foods and beverages with LCSs was estimated by using one 24-h dietary recall. Estimates of the proportion of the population consuming foods and beverages containing LCSs (prevalence of consumption) were weighted to obtain nationally representative results. Trends in prevalence of LCS consumption and mean intake of beverages sweetened with LCSs were tested by using chi-square tests for trend and F tests. Results: In 2007–2008, the percentage of children and adults consuming foods and beverages containing LCSs increased. The prevalence of consuming beverages with LCSs increased from 6.1% to 12.5% among children (P-trend < 0.0001) and from 18.7% to 24.1% among adults (P < 0.001). Increases in the prevalence of consumption of calorie-containing beverages with LCSs were observed among all weight, age, socioeconomic, and race-ethnicity subgroups in both children and adults. However, little change in consumption of no-calorie beverages with LCSs or LCS-containing foods was found. Conclusions: The consumption of LCS-containing beverages has doubled among US children over the past decade. Further research is needed to understand the health effects of this trend.

OBJECTIVE: The aim of this study was to determine if the association with adiposity varies by the type (added vs. naturally occurring) and form (liquid vs. solid) of dietary sugars consumed. METHODS: Data from the 10-year National Heart, Lung, and Blood Institute (NHLBI) Growth and Health Study (n = 2,021 girls aged 9-10 years at baseline; n = 5,156 paired observations) were used. Using mixed linear models, 1-year changes in sugar intake, body mass index z-score (BMIz) and waist circumference (WC) were assessed. RESULTS: The results showed mean daily added sugar (AS) intake: 10.3 tsp (41 g) liquid; 11.6 tsp (46 g) solid and naturally occurring sugar intake: 2.6 tsp (10 g) liquid; 2.2 tsp (9 g) solid. Before total energy adjustment, each additional teaspoon of liquid AS was associated with a 0.222-mm increase in WC (p = 0.0003) and a 0.002 increase in BMIz (p = 0.003). Each teaspoon of solid AS was associated with a 0.126-mm increase in WC (p = 0.03) and a 0.001 increase in BMIz (p = 0.03). Adjusting for total energy, this association was maintained only between liquid AS and WC among all and between solid AS and WC among those overweight/obese only. There was no significant association with naturally occurring sugar. CONCLUSIONS: These findings demonstrate to suggest a positive association between AS intake (liquid and solid) and BMI that is mediated by total energy intake and an association with WC that is independent of it.

Objective. To evaluate parents' beliefs and practices related to childhood obesity and determine if these are influenced by parent's perception of their own weight or their child's weight. Methods. Parents of obese (n = 689) or normal weight (n = 1122) children 4-15 years in Georgia, USA, were randomly selected to complete a telephone survey. Frequency of child obesity-related perceptions, beliefs, and practices were assessed, stratified by parent-perceived self-weight and child weight status, and compared using Chi-squared tests and multivariate logistic regression. Results. Most parents, regardless of perceived child weight, agreed that child overweight/obesity can cause serious illness (95%) but only one-half believed it was a problem in Georgia. Many (42.4%) failed to recognize obesity in their own children. More parents who perceived their child as overweight versus normal weight reported concern about their child's diet and activity and indicated readiness for lifestyle change. Parents' perception of their own weight had little additional impact. Conclusions. While awareness of child overweight as a modifiable health risk is high, many parents fail to recognize it in their own families and communities, reducing the likelihood of positive lifestyle change. Additional efforts to help parents understand their role in facilitating behavior change and to assist them in identifying at-risk children are required.