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Beverages and positive energy balance: the menace is the medium

Abstract

Energy-containing beverages have been implicated in the increasing incidence and prevalence of overweight and obesity. This association has been challenged based on some conflicting evidence and questions about a plausible mechanism. However, the preponderance of epidemiological data indicates that caloric beverage consumption is positively associated with energy intake and body mass index, and this is supported by most intervention trials. Mechanistic questions remain largely unresolved, but there is compelling evidence that caloric beverages elicit weak satiety and compensatory dietary responses. Some attribute this to the components of beverages (e.g., carbohydrate form), but the totality of evidence indicates that the limited appetitive and dietary responses hold across beverage types. This suggests that the fluid medium rather than energy form or nutrient composition is responsible. If true, this hypothesis holds implications for recommendations to the moderate consumption of energy from beverages for example, substitution of one energy-yielding beverage for another may be less effective than reducing intake or switching to lower or non-energy sources.

Introduction

Professor Anderson has prepared a reasoned and well-documented review of the role of sugar-sweetened beverages in energy balance. Given that soda, one such product, is the single largest source of energy in the US diet,1 and the total energy derived from fluids (most of which have carbohydrate as the primary energy source) is growing and presently contributes about 25% of daily energy intake,2 the need to critically assess the literature on this topic is vital. It is especially timely, given the recent publication of guidelines for beverage ingestion by a panel of prominent researchers who were convinced that current intake patterns promote positive energy balance and should be modified to reduce this source of dietary energy, but they did not provide a clear justification for the need to specifically target these products.3 While calling for additional study, Professor Anderson's interpretation of current knowledge would appear to challenge the need for modifying sugar-sweetened beverage intake as he concludes that sugar, as well as sugar-sweetened beverages, decreases food intake and does so as effectively as sugar-sweetened solid foods. Thus, they pose no unique threat to energy balance. Of course, confronted with the same set of observations that do not definitively answer the question, reasonable people can draw different conclusions. Variations in several inferences and conclusions outlined by Professor Anderson are proposed here to further stimulate an objective assessment of this substantive nutritional issue.

Underpinning much of Professor Anderson's review is the belief that, ‘…the unique role proposed for sugar sweetened beverages in obesity is not supported by either experimental studies nor by biological plausibility…’ There are two important aspects of this view. The first concerns the question of whether sugars uniquely promote positive energy balance.

We concur with Professor Anderson's argument that they do not. Rather, it is our view that the medium is more important than the macronutrient source. Weak appetitive and compensatory dietary responses are documented with beverages containing fat4, 5 or protein6 as well. Indeed, it is striking how consistently the high satiety value of protein is documented in solid foods7, 8, 9, 10, 11, 12, 13, 14, 15 but is lost in fluid media.16, 17, 18, 19, 20, 21, 22 Moreover, dietary intake studies overwhelmingly indicate that total energy consumption is higher in alcohol users than in non-users by an amount roughly comparable to the energy added by the alcohol.23, 24, 25, 26, 27, 28 Consequently, while a case can be made that sugar-sweetened beverages are especially problematic in the etiology of obesity because presently they are the most popular beverages, this is probably a scientific red-herring for biological mechanistic studies. The focus should be directed on why beverages per se exert weak satiety effects and how this can be modified.

Our view about the biological plausibility of beverages potentially posing a unique challenge to energy balance diverges from Professor Anderson's. We believe the evidence supporting this role is compelling. First, it meets the criteria established for epidemiological data to support a causal relationship.29 The effects on appetite are:

Consistent – The weak satiety effect of beverages holds for all macronutrients, across the life cycle and in different ethnic groups.30, 31, 32, 33, 34, 35, 36

Strong A direct relationship between beverage consumption and both increased energy intake and body mass index (BMI) is noted in most,36, 37, 38, 39, 40, 41, 42 although not all43, 44, reports.

Specific – The inclusion of beverages in the diet results in positive energy balance and weight gain,45, 46 whereas the removal is associated with reduced energy intake and BMI.47, 48, 49 Indeed, dietary surveys indicate that the addition of a beverage (e.g., alcohol, soda, juice or milk) to a meal leads to increased total energy intake at the meal by an amount roughly equal to the contribution of the beverage.5 Similar findings have been reported over days for soda and alcohol.50, 51

Temporally logical – The prevalence of obesity has increased in concert with beverage consumption. Over the past three decades, daily energy intake from energy-containing beverages increased from 2.8 to 7.0%.52 Total energy intake increased by 150–300 kcal/day since the late 1970s and it has been estimated that approximately 50% of this increase is attributable to beverages.52 Consistent with this view, energy derived from carbohydrate, the principal source of energy in most beverages, has increased disproportionately: 27.2 versus 15.8 and 3.2% for protein and fat, respectively.53 Both the number of servings and serving sizes of beverages have increased.52

Coherent - The increasing consumption of a metabolically available energy source that evokes a weak appetitive and compensatory dietary response would logically promote positive energy balance and weight gain.

Of course, satisfaction of these criteria does not establish causation; intervention trials are needed and available. Controlled studies in rats document that they compensate less well for energy delivered in liquid compared to more solid form (e.g.,54, 55). Human intervention studies have yielded comparable results.31, 45, 56 Supplemental non-energy-containing fluid ingestion is not associated with increased intake or body weight, but addition of an energy source to a fluid leads to increases in both.57 Alternative interpretations of several of these trials have been made. The strength of the meta-analysis56 was challenged stating that exclusion of ethanol, which may influence intake through its psychoactive properties, eliminated the differential compensatory responses to solid and fluid foods, but this is not the case. The comparison remained significant after this adjustment. The crossover study45 was questioned because participants chose to consume the solid and fluid foods in different contexts, snacks versus meals, respectively. Although it could be argued that the design yielded more ecologically valid results by not constraining the behavior of participants, it does hamper the clear resolution of food form and timing effects. However, the pattern yielded effects contrary to expectations based on Continuing Survey of Food Intake (1977–1978 and 1994–1996) data that indicate snacks are the principal source of additional calories in the diet.58 Thus, the inclusion of beverages during meals should have minimized rather than augmented effects.

In addition to the observational and clinical data, biological plausibility is also supported by mechanistic physiological data. There is little doubt that the cognitive, oral, digestive and absorptive processes associated with fluid versus solid food processing differ markedly. Expectations about the energy value of foods exert powerful influences on appetitive responses39, 59, 60 as does mastication61, 62 and the extent and duration of gastric distention and GI transit,63, 64, 65 all of which differ for liquid and solid foods. Further, the efficiency of absorption of macronutrients may differ as solid food forms can be more resistant to mechanical, enzymatic and bacterial degradation, thus reducing the efficiency of energy extraction.66 Higher fiber levels in foods can also result in energy loss.67, 68 Thus, it is biologically plausible that energy-yielding beverages will exert weaker appetitive and compensatory dietary responses than solid foods and thereby lead to positive energy balance and weight gain.

Professor Anderson poses five key questions in his analysis that provide a logical format for delving further into the issue of beverages and obesity. The first is: ‘Do sugars in liquids suppress food intake?’ He states that short-term studies consistently show that sugars suppress short-term food consumption. However, an alternative interpretation of this literature is possible. Part of the evidence cited to support the appetite-suppressing effects of sugars in fluids is based on work with very young children69, 70 who have consistently shown better dietary compensation to all forms of energy preloads. Importantly though, the same workers note that the ability to regulate energy intake under various challenges is lost early in life, perhaps around 5 years of age. Thus, it is not clear whether this work can be extrapolated to adolescents, adults or the elderly. Reports on responses of adults are highly inconsistent, but we believe they are more suggestive of imprecise energy compensation. In a previously published meta-analysis,56 studies where compensation was based on responses to loads relative to the individual's customary energy intake revealed compensation errors ranging from 6 to 80% with a median of 50%. Statistically, this may represent a significant adjustment, but practically the result is positive energy balance. This response to sugars in beverages is not different from responses to other macronutrient manipulations.

Professor Anderson makes an extremely important observation about the limitations of short-term feeding trials. We concur fully that the timing of assessment is critical for their interpretation. Nearly all the work cited to support the intake-suppressing effect of sugar-containing beverages assessed intake within 1 h of loading, with a few extending to 2 h. However, even this longer interval is shorter than the customary eating intervals of the population who eat/drink a mean of about 4.5 times per day.58 The more ecologically relevant question is how individuals will respond to a given load when no constraints are placed on their subsequent behavior. The literature on protein effects highlights this methodological distinction. Reduced energy intake of a test meal presented at a fixed time point (generally 2 h), post-loading, has been documented.71, 72 However, where the testing design entailed monitoring the intake of a meal consumed at the participant's chosen time, the effect is lost.73 This is probably attributable to the effects of lifestyle and cultural influences on food selection (food types and portions), overwhelming the more subtle effects of metabolism.74 If true, this raises questions about the extrapolation of findings from traditional preload paradigms to outcomes in free-living people. Thus, our answer to Professor Anderson's first question is that the literature addressing the issue must be viewed cautiously. It shows sugar-containing beverages elicit only a limited compensatory dietary response, but this is primarily due to the medium rather than the energy source.

The second question posed is, ‘Do sugar sweetened, commercially available beverages suppress food intake?’ Observational39, 75, 76 and intervention77, 78 studies involving school-aged children are cited, that document an association between energy-containing sweetened beverage consumption and increased energy intake, weight gain and obesity. The intervention studies involved monitoring body weight changes associated with restriction of beverage consumption. Not cited are intervention trials with adults who were provided additional commercially available soda. In one trial,79 30 overweight (mean BMI 25.0 kg/m2) adults were provided 1136 g of energy-containing or non-energy-containing soda daily for 3 weeks. Energy intake and body weight increased significantly with consumption of the energy-containing beverages. Body weight decreased (males) or was unchanged (females) with consumption of the non-energy-containing beverages, indicating that weight gain with the energy-containing version was not attributable to fluid intake. In a second crossover trial, the daily provision of 450 kcal of energy-containing soda was contrasted with the ingestion of 450 kcal of jelly beans for 4-week periods.39 Beverage consumption resulted in increased energy intake and body weight, whereas neither was observed with the solid food form. This supports a potential contribution of soda consumption to weight gain, but argues against a role for sugar. Two studies80, 81 are cited that are not consistent with a sugar-sweetened beverage effect on intake. In contrast to the literature supporting a relationship, these are preload studies with the limitations noted above. Further, in one trial81 the effects of soda consumption on meal intake did not differ from the effects following ingestion of orange juice or milk, but all were associated with significantly greater intake compared with a water control. Thus, we believe the preponderance of the evidence indicates that commercially available, energy-containing beverages promote positive energy balance and weight gain rather than suppress it, but this is not attributable to sugar.

Question three was, ‘Do sugars in solid form stimulate intake regulatory systems and suppress food intake more than those in commonly consumed beverages?’ Professor Anderson cites a review devoted to this topic that concludes that the findings are mixed.82 However, the relevance of this review may be questioned on two levels. First, as Professor Anderson notes, few of the included papers were based on a sweetener manipulation. Second, while seven studies are referenced that demonstrate that beverages have lower satiety properties than solid foods,45, 83, 84, 85, 86 none of the nine references reportedly challenging this observation involved beverages. One preload study reporting isoenergetic loads of soda and cookies had similar effects on appetite,81 but it involved feeding individuals who were not hungry with foods not commonly consumed at the time of day when testing was conducted. Thus, the lack of effect may be related to study design. To most appropriately test the question about food form and either appetite or food intake, liquid and solid versions of the same high-sugar foods should be contrasted. There are several examples of studies comparing appetitive responses to fruit juice and the same whole food. Matched for energy, apple juice,84 orange juice86 and grape juice86 have weaker satiety effects than apples, oranges or grapes, respectively. Although close to a true test of food form, even these studies are imperfect as the liquid and solid foods differ somewhat in composition, for example, fiber content. Responses to beverage and solid versions of the identical foods are technically more difficult, but are currently underway. Thus, the weight of the evidence indicates that sugar-containing beverages have weaker satiety values than sugar-containing solid foods.

The fourth question was, ‘Do sugars bypass food intake regulatory systems?’ We fully concur with Professor Anderson that there is no basis to assume sugars uniquely elude intake regulatory systems. We do have a difference of opinion on the role of glucose and insulin as intake regulatory signals. He cites evidence for an association between plasma concentrations of these compounds and appetite and food intake. There can be no dispute that there is a strong association. Following a meal, glucose and insulin levels in the blood rise while hunger declines. The question is whether they are causally related. Euglycemic clamp studies reveal that independent manipulation of plasma glucose and insulin levels does not alter self-reported hunger or fullness.87 Further, foods that are classified as having low or high glycemic properties under standardized testing conditions do not elicit reliable changes in blood glucose, insulin or appetite when consumed in less controlled settings.88, 89 It should also be noted that, at present, there are data indicating that lower glycemic index foods lead to a low insulin response resulting in low leptin release and greater hunger,90 while higher glycemic index foods lead to higher insulin concentrations with consequent hunger and food intake elevation.91 Thus, opposite insulin changes are ascribed to the same effect on appetite. These observations suggest that the various sugars present in foods are more likely to exert their influence on appetite and intake by other mechanisms (e.g., intestinal phase processing, thermogenesis), as outlined by Professor Anderson.

The final question is, ‘How do regulatory systems for hunger and thirst interact to determine energy imbalances?’ There are multiple physiological processes leading to fluid ingestion, but the sensation most commonly prompting drinking is thirst. Hunger is the sensation resulting from processes ensuring an organism maintains adequate energy intake. Although the two systems serve different functions, they are closely linked to ensure body fluid and energy homeostasis. ‘Normal’ drinking occurs peri-prandially in mammals. Rats ingest 70–90% of daily fluid in the period from 10 min before a meal to 30 min following one.92 Data from humans, published two decades ago,93 indicated a similar pattern, with 68% of fluid consumed in association with eating. However, sucrose-sweetened drinks are reportedly less effective than water or aspartame-sweetened beverages in decreasing thirst at a meal.94 Whether this results in greater intake peri-prandially is not known. A number of studies suggest that drinking is not tightly associated with thirst95, 96 and that beverages are increasingly popular snacks.97 This may be problematic because the ingestion of fluids containing either sucrose or salt results in higher continued beverage intake,98 resulting in higher energy intake. It must also be noted that drinking can be entrained through experience and is responsive to cultural cues (e.g., drinking coffee, tea or alcohol socially).95 This then may foster food ingestion as a regulatory response to maintain osmotic balance.99 The effects of different beverages on feeding will be especially important to evaluate. Thus, we fully agree with Professor Anderson that additional study of this issue is needed and may be of great public health importance.

In summary

Sugar-sweetened beverages are widely consumed and deliver a substantive energy load. There is compelling evidence that energy-yielding beverage consumption is associated with weak appetitive and dietary responses. This may result in positive energy balance and overweight or obesity. Consequently, sugar-sweetened beverages may play a role in the etiology and/or maintenance of overweight and obesity. However, the evidence also indicates that this is likely attributable to the medium more than the sugar. This distinction should help focus future research on the role energy-yielding beverages of all types play in energy balance.

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Correspondence to R D Mattes.

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Mattes, R. Beverages and positive energy balance: the menace is the medium. Int J Obes 30, S60–S65 (2006). https://doi.org/10.1038/sj.ijo.0803494

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Keywords

  • beverage
  • energy balance
  • human
  • intake
  • sweetner

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