Substitution of Sugar-Sweetened Beverages with Other Beverage Alternatives: A Review of Long-Term Health Outcomes
Zheng,M., Allman-Farinelli,M., Heitmann,B.L. and Rangan,A., (2015) J.Acad.Nutr.Diet. 115:767-779 S2212-2672(15)00112-4
OBJECTIVE: To examine the effects of substituting beverage alternatives such as plain water, artificially sweetened beverages (ASBs), coffee, tea, 100% fruit juices and milk for sugar-sweetened beverages (SSBs) on long term (>/= 4 months) health outcomes in children and adults.
DESIGN: Systematic review. Included studies were prospective cohort studies and randomised controlled trials (RCTs) examining associations between substitutions of beverage alternatives for SSBs and long-term health outcomes in children and adults.
SETTING: Various (mostly USA).
PARTICIPANTS: Children and adults.
MAIN OUTCOME MEASURES: SSB intake, effects of substitution on total energy intake, body weight and composition, T2-diabetes, stroke, other health outcomes (blood pressure, fasting glucose, urine osmolality).
RESULTS: 10 studies were included in the review (6 prospective cohort studies and 4 RCTs). Two cohort studies were rated as acceptable quality and 4 as high quality, and all RCTs as high quality. All of the cohort studies were in adults and used repeated measures of beverage intake over the study period, assessed by 3 x 24 hour recalls or FFQ. The RCTs were in children, adolescents and adults, ranging from 16 weeks to 2 years in duration, with dietary intake also assessed by FFQ or 24 hour recall.
Total Energy Intake: One cohort study and one RCT examined replacement of SSBs on total energy intake. In overweight women replacing all SSBs with water was associated with a mean decrease of 200kcal/day over 12 months (P<0.05) whereas replacing with low-calorie beverages predicted a mean decrease of 140kcal/day over 12 months. There was no calorie intake benefit with calorie-containing alternatives.
Body weight and composition: The available evidence from 2 cohort studies and 3 RCTs suggests a favourable effect of replacing SSBs with low-calorie alternatives such as water, coffee/tea, and ASBs on long-term body weight and 1 RCT found no effect for substitution with milk in overweight and obese children. Outcome measures included calorie reduction, change in body weight, change in % body fat, change in waist circumference, and change in BMI. Findings from the individual studies included: replacing all SSBs with water over 12 months in overweight women was associated with a 3kg weight loss, 3.4 cm decrease in waist circumference and a 1.9% decrease in % body fat, with low-calorie alternatives associated with a reduced benefit (30% less than water) and calorie-containing beverages had no effect; replacing water, coffee, tea, ASBs and low-fat milk for SSBs were all significantly and inversely related to weight gain over 16-20 years; a 25-week RCT in adolescents substituting SSBs with ASBs or water found a significant effect on BMI between groups for the upper BMI baseline tertile; a 16-week RCT in overweight and obese children found no significant effect of SSB substitution with milk on change in weight or % body fat; a 2-year RCT in adolescents (1 year active intervention substituting SSBs with ASBs or water, and 1 year follow-up) found a significant decrease in BMI and body weight at 1 year between groups, but no differences at 2 years; and a 6-month study in overweight and obese adults reported a significant reduction in body weight and waist circumference when substituting water or ASB for 2 servings/day of calorie-containing beverages.
T2-diabetes: 2 cohort studies found beneficial effects of substituting SSBs on risk of T2-diabetes. In one study, substitutions of plain water, coffee or milk, and ASBs or tea for SSBs were significantly associated with lower risk of type 2 diabetes ranging from 7-8%, 12-17% and 5-7%, respectively, over 20 years.
Stroke: 1 study reported on beneficial effects of substituting SSBs with other beverages on incidence of stroke. Substitutions with decaffeinated and caffeinated coffee were significantly associated with a 9-10% reduction in risk, and low-fat milk was associated with 8% reduced risk.
CONCLUSIONS: SSB substitution with beverage alternatives such as water and low-calorie beverages may have beneficial effects on long-term body weight management. However, the evidence of beverage substitution on other health outcomes is insufficient to draw conclusions. The optimal beverage alternative to SSBs has not yet been determined and may vary according to age group and/or disease outcome. It is important to use age-appropriate substitution strategies for reducing SSB consumption to achieve anticipated beneficial effects on longer-term health outcomes. It may be important to include population level education strategies for suitable beverage substitutions in addition to policy-level changes and soda taxes.
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