Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St Michael's Hospital, Toronto, Ontario, Canada.
JAMA Netw Open. 2022 Mar 1;5(3):e222092. doi: 10.1001/jamanetworkopen.2022.2092.
There are concerns that low- and no-calorie sweetened beverages (LNCSBs) do not have established benefits, with major dietary guidelines recommending the use of water and not LNCSBs to replace sugar-sweetened beverages (SSBs). Whether LNCSB as a substitute can yield similar improvements in cardiometabolic risk factors vs water in their intended substitution for SSBs is unclear.
To assess the association of LNCSBs (using 3 prespecified substitutions of LNCSBs for SSBs, water for SSBs, and LNCSBs for water) with body weight and cardiometabolic risk factors in adults with and without diabetes.
Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception through December 26, 2021.
Randomized clinical trials (RCTs) with at least 2 weeks of interventions comparing LNCSBs, SSBs, and/or water were included.
Data were extracted and risk of bias was assessed by 2 independent reviewers. A network meta-analysis was performed with data expressed as mean difference (MD) or standardized mean difference (SMD) with 95% CIs. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the certainty of the evidence.
The primary outcome was body weight. Secondary outcomes were other measures of adiposity, glycemic control, blood lipids, blood pressure, measures of nonalcoholic fatty liver disease, and uric acid.
A total of 17 RCTs with 24 trial comparisons were included, involving 1733 adults (mean [SD] age, 33.1 [6.6] years; 1341 women [77.4%]) with overweight or obesity who were at risk for or had diabetes. Overall, LNCSBs were a substitute for SSBs in 12 RCTs (n = 601 participants), water was a substitute for SSBs in 3 RCTs (n = 429), and LNCSBs were a substitute for water in 9 RCTs (n = 974). Substitution of LNCSBs for SSBs was associated with reduced body weight (MD, -1.06 kg; 95% CI, -1.71 to -0.41 kg), body mass index (MD, -0.32; 95% CI, -0.58 to -0.07), percentage of body fat (MD, -0.60%; 95% CI, -1.03% to -0.18%), and intrahepatocellular lipid (SMD, -0.42; 95% CI, -0.70 to -0.14). Substituting water for SSBs was not associated with any outcome. There was also no association found between substituting LNCSBs for water with any outcome except glycated hemoglobin A1c (MD, 0.21%; 95% CI, 0.02% to 0.40%) and systolic blood pressure (MD, -2.63 mm Hg; 95% CI, -4.71 to -0.55 mm Hg). The certainty of the evidence was moderate (substitution of LNCSBs for SSBs) and low (substitutions of water for SSBs and LNCSBs for water) for body weight and was generally moderate for all other outcomes across all substitutions.
This systematic review and meta-analysis found that using LNCSBs as an intended substitute for SSBs was associated with small improvements in body weight and cardiometabolic risk factors without evidence of harm and had a similar direction of benefit as water substitution. The evidence supports the use of LNCSBs as an alternative replacement strategy for SSBs over the moderate term in adults with overweight or obesity who are at risk for or have diabetes.
重要性：有人担心低热量和无热量甜味饮料 (LNCSBs) 没有既定的益处，主要的饮食指南建议使用水而不是 LNCSBs 来替代含糖饮料 (SSBs)。LNCSB 是否可以作为替代物，在替代 SSBs 方面，与水相比，是否可以产生类似的改善心血管代谢风险因素的效果尚不清楚。
目的：评估 LNCSBs（使用 3 种预先指定的 SSBs 替代物、水替代 SSBs 和 LNCSBs 替代水）在有或没有糖尿病的成年人中与体重和心血管代谢风险因素的关联。
数据来源：从创建到 2021 年 12 月 26 日，在 Medline、Embase 和 Cochrane 对照试验中心注册库中进行了检索。
研究选择：纳入了至少有 2 周干预的随机临床试验 (RCTs)，比较了 LNCSBs、SSBs 和/或水。
数据提取和合成：由 2 位独立评审员提取数据并评估偏倚风险。使用网络荟萃分析，数据表示为均值差 (MD) 或标准化均值差 (SMD)，置信区间为 95%。使用 GRADE（评估、制定和评估建议的分级）系统来评估证据的确定性。
主要结果和措施：主要结果是体重。次要结果是其他肥胖测量指标、血糖控制、血脂、血压、非酒精性脂肪肝疾病的测量指标和尿酸。
结果：共纳入 17 项 RCTs，共涉及 24 项试验比较，包括 1733 名超重或肥胖且有糖尿病风险或已患有糖尿病的成年人（平均[标准差]年龄 33.1[6.6]岁；1341 名女性[77.4%]）。总体而言，在 12 项 RCTs（n=601 名参与者）中，LNCSBs 替代 SSBs，在 3 项 RCTs（n=429 名参与者）中，水替代 SSBs，在 9 项 RCTs（n=974 名参与者）中，LNCSBs 替代水。LNCSBs 替代 SSBs 与体重减轻（MD，-1.06kg；95%CI，-1.71 至-0.41kg）、体重指数（MD，-0.32；95%CI，-0.58 至-0.07）、体脂百分比（MD，-0.60%；95%CI，-1.03% 至-0.18%）和肝内脂肪含量（SMD，-0.42；95%CI，-0.70 至-0.14）有关。用水分替代 SSBs 与任何结果均无关。用 LNCSBs 替代水与任何结果也没有关联，除了糖化血红蛋白 A1c（MD，0.21%；95%CI，0.02% 至 0.40%）和收缩压（MD，-2.63mmHg；95%CI，-4.71 至-0.55mmHg）。体重和所有其他结果的证据确定性为中度（LNCSBs 替代 SSBs）和低（水分替代 SSBs 和 LNCSBs 替代水）。
结论和相关性：本系统评价和荟萃分析发现，将 LNCSBs 作为 SSBs 的预期替代品，与体重和心血管代谢风险因素的微小改善有关，且没有证据表明有害，并且与水替代具有相似的益处方向。该证据支持在超重或肥胖且有糖尿病风险或已患有糖尿病的成年人中，将 LNCSBs 作为 SSBs 的替代策略，在中度范围内使用。
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