January 2021


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NCCOR Year in Review: 2020

NCCOR, January 28, 2021

Though 2020 was a challenging year for many reasons, NCCOR had one of its most successful years yet. This year, NCCOR launched brand-new resources, collaborated across agencies through workshops, disseminated information at multiple conferences, and more. A special thanks to NCCOR members who worked tirelessly to keep us safe, took on extra work, and worked long hours, all while accelerating childhood obesity research!

Here are some of our top highlights from 2020:

  • Released a new tool for those working on assessing childhood obesity. A Guide to Methods for Assessing Childhood Obesity helps users understand the most common adiposity assessment methods and select the most appropriate method for their objective.
  • Published four papers highlighting findings from  NCCOR’s Childhood Obesity Evidence Base (COEB) Project, a collaborative effort between NCCOR and Mission Measurement to use a novel taxonomic method of data aggregation on obesity prevention efforts for children aged 2-5 years.
  • Published a new paper in the American Journal of Preventive Medicine describing available diet and physical activity measures from NCCOR for populations at high risk for obesity. The paper, Identification of measurement needs to prevent childhood obesity in high-risk populations and environments, reviews NCCOR’s landmark tool, the Measures Registry.
  • Created a new tool, Measures for Children at High-Risk for Obesity, especially for measurement in high-risk populations. The resource includes a decision tree that walks researchers and practitioners through a series of questions regarding whether to develop, adapt, or apply an instrument for obesity measures in high-risk populations. The decision tree also provides five real-world case scenarios that describe the rationale for choosing one of the three measurement approaches.
  • Published “Identification of Effective Programs to Improve Access to and Use of Trails among Youth from Under-Resourced Communities: A Review” in the International Journal of Environmental Research and Public Health. The primary aim of this review paper was to identify programs and policies that effectively promote and increase the use of trails among youth, especially those from under-resourced neighborhoods or communities.
  • Released three new whitepapers that resulted from the Advancing Measurement for Childhood Obesity Workshop Series, funded as part of NCCOR’s Strategic Alliance with The JPB Foundation. The three new whitepapers are, “Advancing Measurement of Individual Behaviors Related to Childhood Obesity,” “Advancing Measurement for High-Risk Populations and Communities Related to Childhood Obesity,” and “Advancing Measurement of Environmental and Policy Influences on Childhood Obesity.”
  • Created a new workgroup to develop a research agenda on childhood obesity and COVID-19.
  • Launched the new NCCOR Student Hub for graduate students and faculty.
  • Released a new fact sheet that shows classroom teachers how to incorporate the Youth Compendium into their curricula.
  • Translated the Youth Compendium of Physical Activities into Spanish to expand our reach internationally.

This list is just a preview. To learn more about NCCOR’s accomplishments in 2020, join our next Connect & Explore webinar on February 10, and stay tuned for our forthcoming 2020 NCCOR Annual Report!

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Publications & Tools

NCCOR’s Toolbox

Check out this new decision tree that walks researchers and practitioners through a series of 10 questions regarding whether to develop, adapt, or apply an instrument to use in high-risk populations.

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Using Systems Applications to Inform Obesity Solutions

The workshop explored various methodologies and tools that could guide future obesity research and action and featured examples of how such approaches have informed decision making within policy and program areas. Workshop presentations also discussed the support structures (e.g., data sources, modeling expertise, training, and partnerships and collaborations) that encourage and engage researchers and decision makers to use systems science approaches to more effectively and efficiently understand the causes of and solutions to the obesity epidemic. This Proceedings of a Workshop-in Brief highlights the presentations and discussions that occurred at the workshop.

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A Special Issue Addressing Healthful Food Access and Food Insecurity: Risk Factors, Behavioral Variables, Interventions, and Measurement

This article introduces a special issue in Translational Behavioral Medicine that focuses on translational aspects of food insecurity research. The purpose of this special issue was to add to the evidence base to inform short- and intermediate-term intervention development and implementation and to spark additional future discourse around these important topics. The special issue included 12 articles and 2 commentaries roughly evenly split across four topic areas, including subpopulation food insecurity risk factors; food behaviors and psychosocial variables; implementation and/or evaluation of food insecurity interventions; and food insecurity-related measurement issues.

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Make Every Bite Count: USDA, HHS Release Dietary Guidelines for Americans, 2020-2025

Nutrition in America took a major step forward today with the publication of Dietary Guidelines for Americans, 2020-2025. Jointly published by the U.S. Departments of Agriculture (USDA) and Health and Human Services (HHS) every five years, the guidelines provide science-based recommendations designed to foster healthy dietary patterns for Americans of all ages – from birth through older adults. Importantly, this edition expands the guidance, for the first time including recommended healthy dietary patterns for infants and toddlers.

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Childhood Obesity Research & News

Changing Diets– Not Less Physical Activity– May Best Explain Childhood Obesity Crisis

EurekAlert!, January 17, 2021

Variation in consumption of market-acquired foods outside of the traditional diet–but not in total calories burned daily– is reliably related to indigenous Amazonian children’s body fat, according to a Baylor University study that offers insight into the global obesity epidemic.

“The importance of a poor diet versus low energy expenditure on the development of childhood obesity remains unclear,” said Samuel Urlacher, Ph.D., assistant professor of anthropology at Baylor University, CIFAR Azrieli Global Scholar and lead author of the study. “Using gold-standard measures of energy expenditure, we show that relatively lean, rural forager-horticulturalist children in the Amazon spend approximately the same total number of calories each day as their much fatter peri-urban counterparts and, notably, even the same number of calories each day as children living in the industrialized United States.

“Variation in things like habitual physical activity and immune activity have no detectable impact on children’s daily energy expenditure in our sample,” he said.

The study — “Childhood Daily Energy Expenditure Does Not Decrease with Market Integration and Is Not Related to Adiposity in Amazonia” — is published in The Journal of Nutrition, the American Society for Nutrition’s flagship journal, and was funded by the National Science Foundation.

“That initial result alone is exciting in confirming our prior finding of relative stability in children’s daily energy expenditure across different lifestyles and environments,” Urlacher said. “But our study goes further. It shows that Amazonian children who eat more high-calorie market foods — but not those who spend fewer calories every day — consistently have more body fat.

“Together, these findings support the view that change in diet is likely the dominant factor driving the global rise in childhood obesity, particularly in the context of rapid urbanization and market integration in low- and middle-income countries,” he said.

The global rate of overweight/obesity among school-age children and adolescents has risen from 4% in 1975 to 18% as of 2016, according to the NCD Risk Factor Collaboration. That reflects a major global health crisis. Children who are overweight/obese often remain so into adulthood. They have shorter life expectancy and a greater lifetime risk of developing noncommunicable diseases, including Type 2 diabetes and heart disease.

“While the most rapid rise in childhood overweight and obesity is now in rural areas and in low- and middle-income countries, few previous studies have actually measured, rather than simply estimated, children’s energy expenditure in these settings to identify the cause of energy imbalance,” Urlacher said.

To investigate school-age children’s diets and energy expenditure during early market integration and transition to overweight/obesity, Urlacher and co-researchers* collected data among 43 rural and 34 peri-urban Shuar children in Amazonian Ecuador. The Shuar are a large indigenous population of around 50,000. Children in the rural study sample live in a geographically isolated region and rely predominantly on a subsistence-based lifestyle based on hunting, fishing, foraging and small-scale horticulture. In contrast, children in the peri-urban study sample live in a regional market center with access to roads, a hospital, stores, restaurants and other market amenities.

To measure variation in market integration among households, researchers collected information on things such as income and access to running water. They also measured children’s physical activity using wearable devices and immune activity by measuring biomarkers in minimally invasive finger-prick blood samples. Most importantly, the researchers measured children’s daily energy expenditure using the “doubly labeled water” stable isotope-tracking method and children’s resting energy expenditure using respirometry – both participant-friendly, gold-standard techniques.

The study found that:

Peri-urban children average 65% more body fat than rural children, with more than a third of peri-urban children classified as overweight compared to zero rural children.

Peri-urban children eat more than four times as many market-acquired items as rural children.

Peri-urban and rural children have similar levels of physical activity.

Peri-urban children spend 108 calories per day less than rural children while at rest. This is related in part to 16-47% lower levels of immune activity.

Measures of market integration, immune activity and physical activity have no detectable impact on children’s overall energy expenditure, with peri-urban and rural children spending roughly the same number of calories.

Variation in consumption of market foods, but not in daily energy expenditure, is related to children’s body fat.

The study is the first to measure children’s energy expenditure across market integration in a single population simultaneously with measures of diet, physical activity and immune activity. The finding of no effect of market integration on measured daily energy expenditure is consistent with previous reports among adults and infants, Urlacher said. It also supports an evolutionary model of childhood energy constraint and allocation trade-offs described in detail by the researchers in their 2019 paper published in the journal Science Advances.

By measuring multiple aspects of the energy balance equation simultaneously, the researchers believe that their findings provide persuasive evidence for a likely primary role of changing dietary intake, rather than reduced daily energy expenditure, in driving the rise in childhood obesity in many populations.

“Our findings are in line with a growing body of research pointing toward poor diet being the most important factor underlying the development of childhood obesity,” Urlacher said. “Exercise is absolutely still a critical part of this equation and is essential for living a healthy life, but diet increasingly appears to be most directly related to children’s adiposity and long-term energy balance.”

The researchers plan to advance this work by collecting longitudinal data to assess individual children’s lifetime development of obesity and cardiometabolic diseases. They also plan to collect more detailed dietary data and analyze a wider range of lifestyle and biological factors to identify causal pathways. Central to these efforts is determining how to best apply findings to improve children’s health in low- and middle-income countries.

“Childhood obesity is a complex problem that must be addressed on many different levels, ranging from the biological to the environmental, economic, social and political,” Urlacher said.

“At the end of the day, everyone working on this problem wants the same thing: to improve children’s lifelong health and well-being. We hope that this work can ultimately contribute to that effort, particularly for the Shuar whose generosity and partnership made this research possible.”

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Fast Food Restaurant Proximity Likely Doesn't Affect Children's Weight

January 14, 2021, EurekAlert!

A new paper in Q Open finds that the availability of fast food restaurants on the route between children’s houses and their schools does not affect children’s weight.

Reducing the rate of childhood obesity is a top public health priority in the United States where obesity rates are 18.4% for those ages 6-11 and 20.6% for those ages 12-19. Childhood obesity is a documented risk-factor for negative physical and mental health outcomes. Obese children are also more likely to become obese adults and suffer associated health problems.

Researchers have proposed that the accessibility of affordable healthy food options may be an important determinant of childhood weight. Many public health figures are concerned about the role of fast-food restaurants on food consumption and resulting obesity in children. Local governments in the United States have the power to influence children’s food options through the zoning process. Several cities, including Austin, Texas, and New York, have considered banning fast-food restaurants near schools.

This article investigates the effect of fast-food availability on childhood weight outcomes by gender, race, and location. The researchers used a novel identification strategy based on changes in fast food exposure along the route between home and school that occur as students progress through the public school system and transition to different types of schools, e.g., from elementary schools to intermediate schools or from intermediate schools to high schools.

Researchers here used Arkansas student Body Mass Index, collected from 2004 to 2010, and matched it to home and school address through annual school registration records. Home address was used to geocode the location of student residences.

The researchers identified fast-food restaurants on the route between children’s houses and their schools. Fast food restaurants included the major hamburger chains and drive-in restaurants (e.g. McDonalds, Burger King, Wendy’s), dairy stores with large fast-food menus (e.g., Dairy Queen), take-out pizza establishments, quick-service taco places (e.g., Taco Bell), sandwich delicatessens (e.g., Subway, Quiznos), and fried chicken restaurants (e.g., KFC, Chick-Fil-A). The researchers excluded specialty stores such as ice-cream parlors not selling other fast foods (e.g., Baskin-Robbins), coffee shops (e.g. Starbucks), and donut shops (e.g. Krispy Kream).

Using a radius of one-half mile to define exposure near home and school, the mean total exposure level is 3.34 restaurants. The majority of children in the sample had zero exposure within 0.5 miles of home (69.6%). In contrast, 45.2% of children have at least one fast-food restaurant located within 0.5 miles of their school.

Researchers then measured changes in fast-food exposure as students changed schools as a result of a natural progression through the school system over time, for example, the change from elementary school to junior high school, and thus had different exposure to fast food restaurants. The researchers found that changes in exposure have no effect on BMI z- score.

For example, increasing fast-food exposure by three restaurants moving from 4th to 10th grade increased the mean change in BMI by .003, less than one percent (0.7%) of the standard deviation.

Ultimately the researchers find no meaningful association between fast-food exposure along the route to school and BMI. This conclusion holds across different ages of children and for subsamples by gender, race, and ethnicity. The researchers also found no differences by income as measured by whether the child qualifies for free or reduced-price school lunches or between urban and rural children. These findings suggest that simple exposure to fast-food establishments in the commercial food environment was not a primary driver of excess childhood weight gain among children. While it is possible that fast food restaurants matter but their effects on BMI are longer-term, the researchers found no evidence that longer exposures as in the 4th to 8th grade transition differ meaningfully from the 4th to 6th or 6th to 8th grade transitions.

“Policies that place restrictions on actions of individuals and businesses are costly,” said the paper’s author, Michael R. Thomsen. ” We see this with the response to Covid-19. Even when imposed with the most well-intentioned of objectives, people resist attempts to constrain their will. If governments are going to pursue a strategy that requires the investment of time and monetary resources to get a policy passed and enforced, it must be for tangible good, not simply a feeling of having done something. Although there is a strong correlation between the availability of fast-food and obesity, the evidence for a causal relationship remains weak. With limited political capital, policy fights over limiting access to fast-food may not be worth the public health returns.”

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Landmark Study Reveals Link Between Gut microbes, Diet and Illnesses

EurekAlert! January 11, 2021

Diets rich in healthy and plant-based foods encourage the presence of gut microbes that are linked to a lower risk of common illnesses including heart disease, research has found.

A large-scale international study using metagenomics and blood chemical profiling has uncovered a panel of 15 gut microbes associated with lower risks of common conditions such as obesity and type 2 diabetes. The study has been published today in Nature Medicine from researchers at King’s College London, Massachusetts General Hospital (MGH), Harvard T.H. Chan School of Public Health, the University of Trento, Italy, and health start-up company ZOE.

The PREDICT 1 (Personalized Responses to Dietary Composition Trial 1) analyzed detailed data on the composition of participants’ gut microbiomes, their dietary habits, and cardiometabolic blood biomarkers. It uncovered strong links between a person’s diet, the microbes in their gut (microbiome) and their health.

Researchers identified microbes that positively or negatively correlate ‘good’ and ‘bad’ with an individual’s risk of certain serious conditions such as diabetes, heart disease and obesity. Surprisingly, the microbiome has a greater association to these markers than other factors, such as genetics. Some of the identified microbes are so novel that they have not yet been named.

The researchers defined a “healthy” diet as one that contained a mix of foods associated with a lower risk of chronic disease. They found that trial subjects who ate such a diet, or one rich in plants, were more likely to have high levels of specific ‘good’ gut microbes which are associated with a low risk of common illnesses. The researchers also found microbiome-based biomarkers of obesity as well as markers for cardiovascular disease and impaired glucose tolerance, which are key risk factors for COVID. These findings can be used to help create personalized eating plans designed specifically to improve one’s health.

Dr. Sarah Berry, Reader in Nutrition Sciences at King’s College London said, “As a nutritional scientist, finding novel microbes that are linked to specific foods, as well as metabolic health, is exciting. Given the highly personalised composition of each individuals’ microbiome, our research suggests that we may be able to modify our gut microbiome to optimize our health by choosing the best foods for our unique biology.”

For example, the findings reveal that having a microbiome rich in Prevotella copri and Blastocystis species was associated with maintaining a favorable blood sugar level after a meal. Other species were linked to lower post-meal levels of blood fats and markers of inflammation.

Professor Tim Spector, Epidemiologist from King’s College London, who started the PREDICT study program and is scientific founder of ZO, said: “When you eat, you’re not just nourishing your body, you’re feeding the trillions of microbes that live inside your gut.”

Nicola Segata, PhD, professor and principal investigator of the Computational Metagenomics Lab at the University of Trento, Italy and leader of the microbiome analysis in the study, said: “We were surprised to see such large, clear groups of what we informally call ‘good’ and ‘bad’ microbes emerging from our analysis. It is also exciting to see that microbiologists know so little about many of these microbes that they are not even named yet. This is now a big area of focus for us, as we believe they may open new insights in the future into how we could use the gut microbiome as a modifiable target to improve human metabolism and health.”

PREDICT is the largest in-depth nutritional study in the world. PREDICT 1 was an international collaboration to study links between diet, the microbiome, and biomarkers of cardiometabolic health. The researchers gathered microbiome sequence data, detailed long-term dietary information, and results of hundreds of cardiometabolic blood markers from just over 1,100 participants in the U.S. and the U.K. PREDICT 2 completed its primary investigations in 2020 with a further 1,000 U.S participants, and PREDICT 3 launched a few months ago.

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New Study Shows Correlation Between Teen Obesity and Mental Health Issues

EurekAlert! January 19, 2021

Half of all young people treated for severe obesity have neuropsychiatric problems, according to a new study by researchers from Lund University and Gothenburg, Sweden, among others. Two thirds of the teens suffered from some type of mental health problem, as reported by themselves or their parents.

Both obesity and mental illness have increased among young people during the 2000s. Researchers have long observed a connection between obesity and ADHD/depression/eating disorders, but it has seldom been studied.

The present study involved 48 teenagers (73% girls), with an average age of 15 and an average BMI of 42, which is severe obesity. Half of the participants received medical treatment for obesity, while the other half underwent surgery.

The teenagers’ parents completed questionnaires to measure their children’s symptoms of ADHD and autism. The adolescents themselves responded to questions about binge eating and symptoms of depression.

The results show that over half of the parents estimated that their teenagers had difficulties resembling ADHD and/or autism, despite only a few of them having been previously diagnosed with these conditions.

“Symptoms of ADHD mean that the person has difficulty with impulse control. This increases the risk of eating without being hungry and the tendency to opt for quick solutions such as fast food”, says Kajsa Järvholm, a psychology researcher at Lund University and the University of Gothenburg.

“People on the autism spectrum are sometimes more selective in their eating than others. They only accept certain dishes but may eat more of them as a result”, she says.

One fifth of the adolescents reported suffering symptoms of depression. One third of them reported problems with binge eating, which is a loss of control resulting in the person eating large quantities of food in a short time.

“Contrary to our expectations, the adolescents with neuropsychiatric difficulties did not have more problems with binge eating and depression than the other adolescents in the group”, says Järvholm.

Altogether, the information provided by the parents and adolescents revealed that two thirds of the patients in the study had difficulties arising from neuropsychiatric problems, binge eating and/or depression.

The researchers believe that the findings reveal a need to personalise treatments for adolescents with severe obesity as the majority also reported mental illness.

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Systematic Review Into City Interventions to Address Obesity

The Lancet, January 7, 2021

Obesity threatens to undo the improvements that have been made in life expectancy over the last two centuries. It disproportionately affects lower socioeconomic and ethnic minority groups and has become one of the most important global health challenges of the 21st century. Whilst obesity is not confined to city populations, cities are home to more than half of the world’s population with concentrated groups at high risk of obesity. Cities have also long been the forefront of social and technological change that has led to our current obesogenic environment. The aim of this study was to systematically identify city-wide interventions to address obesity, from which recommendations for policy makers, health system leaders and political leaders in cities could be made.

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Sugar-Sweetened Beverage Taxes: Lessons to Date and the Future of Taxation

PLOS Medicine January 7, 2021

To date, across the globe, over 45 countries, cities, and regions have instituted sugar-sweetened beverage (SSB) taxes.

Why tax SSBs?

We see at least 2 major health-related reasons to focus on SSBs. First, excess sugar consumption is a major cause of obesity and the increasing risk of type 2 diabetes, hypertension, liver and kidney damage, heart disease, and some cancers. Second, high-caloric beverages offer little caloric compensation, so reducing their consumption lowers obesity risk. Furthermore, we are beginning to understand the potential impacts of these beverages on stunting as well as obesity. A less emphasized reason that deserves greater attention as we consider the links between our diets and planetary health is the environmental costs related to the production of sugary drinks, particularly in water use and carbon emissions. Estimates of total water lifecycle costs to produce a half-liter (or 17-ounce) regular soft drink range from 168 to 309 liters, depending on the sugar source and farm technology. Finally, from a practical standpoint, SSB taxes have gained momentum because of their relative ease of implementation compared to other food/nutrition policy options. Taxes collected from manufacturers, bottlers, and distributors can often be built into existing taxation frameworks and collection systems, and these health taxes are a potential source of revenue.

What have we learned from major evaluations to date?

Three recent papers published in PLOS Medicine highlight the potentials of different methods of discouraging SSB consumption among the public and encouraging reformulations by the beverage industry. In the United Kingdom, the multitiered Sugar Drinks Industry Levy based on sugar content has prompted remarkable reformulations and shifts in purchases with new low-calorie beverages emerging. In Portugal, earlier findings suggest both sugar reduction in beverage formulations and reduced sales, and the latest paper by Goiana-da-Silva and colleagues simulates its implication for lowering new cases of obesity in children, adolescents, and adults. Likewise, reformulations are an important driver of change in response to Chile’s integrated food labeling, marketing, and school food regulations. Taillie and colleagues’ new study found a 23.7% reduction overall in the volume of SSBs purchased and a 27.5% decline in calories consumed per capita per day. While reductions in SSB purchases and modeled improvements in obesity outcomes address the objectives of these policies, the implications of reformulations are unclear and need monitoring.

Overall, price changes are heterogeneous depending on the baseline levels of consumption, market shares of beverage brands given the geographic coverage of the tax, and reflect strategic behaviors by beverage companies and retailers. Consequently, changes in consumption are also heterogeneous, particularly across income levels, age groups, and baseline beverage levels. Nonetheless, a meta-analysis shows that the average consumer will lower his/her SSB purchases by 10% if SSB prices rise 10% (price elasticity of demand of −1). Health implications (e.g., weight change, flattening of diabetes prevalence rates, or reductions in obesity incidence) take years to emerge at the population level, so researchers have used the available results to estimate longer-term health and economic implications, such as in the recent analysis by Goiana-da-Silva and colleagues.

The findings to date suggest that future SSB tax designs need to consider the baseline levels of consumption of various beverages stratified by income and the price elasticities of demand that can guide the scope of the products covered. Second, the tax structure should be aligned with the primary objectives. If the goal is reduction of sugar consumption, then one based on sugar density is more likely to achieve the goal, as the Portugal and UK results suggest. If the goal is revenue generation, then a volume-based specific tax across a broad scope of beverages may result in greater revenue given a weaker incentive to reformulate. Meanwhile, studies have shown that ad valorem taxes on SSBs are less likely to be fully pass through onto prices compared to specific taxes in the form of sales taxes (rather than excise taxes). Finally, the geographic coverage of the tax jurisdiction has implications for ease of cross-border shopping and highlights the need for national- or province/state-level taxes over local taxes.

A critical concern from the health perspective is the reductions in sugar and caloric intakes through reduced SSB consumption. While these taxes specifically affect high consumers, evaluations to date suggest that the reductions affected by SSB taxes translate to 5 to 22 kilocalories (kcals) per capita per day. These levels of reductions, even if sustained, are insufficient to meaningfully impact the broad swath of health outcomes in a timely manner, although research shows that the 10- to 20-year time horizon will produce important results. One way to address this is to raise the current tax rates that are in the 5% to 20% range. A few Middle Eastern countries (e.g., Saudi Arabia, Qatar, and the United Arab Emirates) have instituted 50% to 100% excise taxes on subsets of SSBs, and Bermuda has implemented a 75% import tax on sugar, SSBs, and candies. We can learn from tax levels for tobacco (another product with no health benefits and many costs) where the taxation rates range from 100% to 1,000%

Potential unknown consequences

Evidence to date demonstrates that sugar reduction policies will and have resulted in the introduction of beverages with both sugar and nonnutritive sweeteners (NNSs).

NNS consumption is growing in high-income countries, but it is less clear what will happen in low- and middle-income countries, where consumption of diet beverages is minimal. The Mexican and Berkeley evaluations found a shift toward water. The few studies in low-income countries have found a small movement toward NNS-sweetened beverages, but that might change with large tax rates on SSBs or ultraprocessed foods.

So why the concern around NNSs? One fear is the impact on sweetness preference and habituation among children. Among adults, we see different outcomes in widely conflicting human studies looking at gut health, brain response, and heart health. At present, no global consensus on the longer-term health implications of prolonged and/or larger doses of NNS intake exists. The dearth of information on their use (the types and amounts) in our food supply means that it is challenging to study these questions.

A few Latin American countries are exploring front of package labeling to inform consumers if products contain NNSs. Additional information on the amounts of the various NNSs will allow monitoring of our exposure to these additives and population-based observational studies on health outcomes of the types and amounts of NNSs in diets. Currently, Chile is the only country, to our knowledge, that requires the amount of each type of NNS on nutrition labels.

Of course, the food industry constantly undertakes research and development, and the scientific community’s understanding of how the various combinations of foods, ingredients, and chemicals we are exposed to affects our health over time is still growing. Any new regulations targeting current attributes of concern will meet subsequent introductions of new ingredients and products to avoid or minimize such regulations. Researchers and regulatory agencies must be vigilant and thoughtful in establishing mechanisms with which to periodically assess and improve these regulations to ensure that they evolve with the food landscape to best protect people’s health.


Taxation of SSBs is an important start to using fiscal policy to correct the large human and planetary costs of the modern food supply chain and promote improved diet and eventually health. SSB taxes to date have varied in design, and continued assessments can allow us to better understand how to improve them to sharpen their effects. To date, tax rates are often too low, and the net impact, while important for public health, needs to be increased significantly. Increasing SSB taxation levels or expanding the tax base to include unhealthy ultraprocessed foods and beverages offer options. Additionally, the tax revenues should be directed toward human capital investments, particularly those targeting lower-income individuals or households, to address equity concerns and strengthen public support. Regardless, careful monitoring of industry responses to taxes is important due to industry investments in new food technologies with unknown, longer-term implications on human and planetary health.

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