Outcomes of a systematic review and network meta-analysis of clinical trials conducted by the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes (EASD) to inform the EASD Clinical Practice Guidelines for Nutrition Therapy
- A new systematic review and meta-analysis of randomised controlled trials (RCTs) confirms a beneficial role of low/no calorie sweetened beverages in reducing body weight and cardiometabolic risk factors, when these drinks substitute sugar-sweetened beverages in the diet.
- Low/no calorie sweetened beverages were associated with reduced body weight, body mass index, percentage of body fat, and intrahepatocellular lipid in adults with overweight or obesity who are at risk for or have diabetes, when compared with sugar-sweetened beverages.
- Their benefits were similar to those of water, the standard-of-care substitution, making low/no calorie sweetened beverages a helpful alternative replacement strategy for sugary drinks.
A clear guidance on the role of beverages sweetened with low/no calorie sweeteners in sugar reduction strategies is currently lacking in major dietary guidelines as concerns remain about their impact on cardiometabolic health. To provide evidence that could help inform guidance on the intake of low/no calorie sweetened beverages, as the intended substitute for sugar-sweetened beverages (SSBs), a new study, published in JAMA Network Open, was conducted by the experts of the Diabetes and Nutrition Study Group (DNSG) of the European Association for the Study of Diabetes (EASD).1 The nutrition and diabetes experts reviewed and analysed all available studies that have investigated the effects of low/no calorie sweetened beverages on weight outcomes and cardiometabolic factors, and examined whether low calorie drinks, as substitutes for SSBs, can yield similar improvements as water.
Why is this study important?
The present study is significant for three main reasons. First, it is aimed at informing the Clinical Practice Guidelines for Nutrition Therapy of the European Association for the Study of Diabetes. Second, the methodology used in the study is a key strength. The use of network meta-analysis provided more precise estimates than single direct or indirect estimates and, in addition, allowed for the simultaneous assessment of three substitutions (low calorie beverages for SSBs, water for SSBs, and low calorie beverages for water), leveraging direct and indirect comparisons with a common comparator to increase the information size. Finally, the DNSG experts conducted a comprehensive literature search that included only RCTs, which provide higher quality of evidence and the greatest protection against bias.
How was the study conducted?
The network meta-analysis included 17 RCTs with 24 comparisons and with a median study duration of 12 weeks, involving 1733 adult participants with overweight or obesity who were at risk for or had diabetes. The trials examined the association of beverages with cardiometabolic risk factors (adiposity, glycemia, blood lipids, blood pressure, non-alcoholic fatty liver disease [NAFLD], and uric acid). Three prespecified substitutions were used: low/no calorie sweetened beverages for SSBs (intended substitution with caloric displacement), water for SSBs (standard-of-care substitution with caloric displacement), and low/no calorie sweetened beverages for water (reference substitution without caloric displacement).
What did the study results show?
The findings of this study support the assertion that substituting sugar-sweetened beverages with low/no calorie sweetened beverages is associated with reductions in body weight and cardiometabolic risk factors, with no evidence of harm. These improvements were similar in direction to those associated with water substitution, the standard of care.
Specifically, the study results showed that the intended substitution of SSBs with low/no calorie sweetened beverages was associated with small but significant reductions in body weight (−1.06 kg; −1.71 to –0.41 kg), body mass index, percentage of body fat, and intrahepatocellular lipid, with moderate certainty of evidence. Also, there was no evidence of harm or adverse events associated with this substitution. A small reduction in body weight was also associated with low/no calorie sweeteners compared with water, while water was associated with lower level of glycosylated haemoglobin and low/no calorie sweetened beverages with a greater decrease in systolic blood pressure compared with water. Finally, for the comparison between SSBs with water, neither body weight nor any other outcomes showed significant differences, although the direction of association favoured water for most of the outcomes.
What do these findings mean for people living with overweight or obesity?
People living with overweight or obesity who are at risk for or have diabetes should be able to enjoy a variety of healthy, safe and tasteful foods and drinks in their efforts to manage their body weight and blood glucose levels. The results of this study confirm that, over the moderate term, low/no calorie sweetened beverages can be a practical alternative to water as a replacement strategy for sugary drinks and, when consumed as part of a healthy diet and lifestyle, can help people living with overweight or obesity in their weight control efforts.
The study results are also in line with findings of other systematic reviews.2-7 Low/no calorie sweeteners can be used in food and beverages to provide a wide choice of sweet-tasting options with low or no calories. Thus, they can be a useful tool, when used in place of sugar and as part of a balanced diet, in helping reduce overall sugar and calorie intake2-4, and in turn in body weight control4,5 as well as in managing blood glucose levels6,7.
The nutrition and diabetes experts of DNSG and authors of this study conclude that these findings can inform guidance on the role of low/no calorie sweetened beverages in sugar-reduction strategies.