Review Article

A narrative review of the effects of sugar-sweetened beverages on human health: A key global health issue

Mainul Haque1, Judy McKimm2, Massimo Sartelli3, Nandeeta Samad4, Seraj Zohurul Haque5 and Muhamad Abu Bakar6

1Department of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, 57000 Kuala Lumpur, Malaysia

2Department of Medical Education, Swansea University School of Medicine, Swansea University, Singleton Park, Swansea, Wales, United Kingdom

3Department of Surgery, University of Macerata, Macerata Hospital, Via Giovanni Mario Crescimbeni, Macerata MC, Italy

4Department of Public Health, North South University, Dhaka, Bangladesh

5Department of Orthopedics, School of Medicine, University of Dundee, Ninewells Hospital & Medical School DD1 9SY, United Kingdom

6Department of Otolaryngology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), 3, Jalan 4/27a, Seksyen 2 Wangsa Maju, 53300 Kuala Lumpur, Wilayah Persekutuan Kuala Lumpur, Malaysia

Corresponding author: runurono@gmail.com

Submitted: 10 January 2020. Accepted: 12 February 2020. Published: 3 March 2020.

DOI: 10.15586/jptcp.v27i1.666

ABSTRACT

The provision of healthy and safe food is vital for human health, and the addition of unnecessary sugars in foodstuffs is an important global issue, leading to multiple long- and short-term health issues and spiraling costs for individuals and governments alike. The negative effect of excess sugar consumption contributes to adverse health conditions, including obesity, type 2 diabetes, and poor oral health in both high and low resource settings. A key plank of governmental and health promotion bodies’ nutritional guidance is to raise public awareness of “hidden” sugars, salt, and fats, such as found in processed foods and sugar-sweetened beverages (SSBs), and guide individuals to reduce their consumption. This rapid narrative review brings together some of the key issues identified in the literature around the consumption of SSBs, including patterns of consumption, the general impact on human health and nutrition, specific effects on oral health and the oral microbiome, and strategies to address over-consumption. The range of long-term adverse effects on health is often misunderstood or unknown by the public. However, some strategies have succeeded in reducing the consumption of SSBs, including public health strategies and interventions and the imposition of taxes or levies, and this article makes recommendations for action.

Keywords: effects; sugar-sweetened beverages; SSBs; consumption; tax; diabetes; cardiovascular diseases; weight gain and obesity; cancer; nutrition and diet quality; nutrition; mortality; morbidity; global health

 

INTRODUCTION

The World Health Organization (WHO) defines a healthy diet as including a diverse mix of foods and nutrients, including “staples like cereals (wheat, barley, rye, maize, or rice) or starchy tubers or roots (potato, yam, taro, or cassava); legumes (lentils and beans); fruit and vegetables; foods from animal sources (meat, fish, eggs, and milk).”1 Similarly, many governments and health promotion bodies have produced nutritional guidelines emphasizing the need for people of all ages to have a balanced diet, with a mix of fresh vegetables and fruit, proteins such as meat, fish, soya, legumes, or pulses, vegetable oils, complex carbohydrates, milk and dairy products, and clean water.2,3 The negative effects of excess sugar consumption are widely known around the world and contribute toward increasing health conditions (including obesity, type 2 diabetes, and poor oral health) in both high- and low-resource settings.4–12 While the WHO recommends limiting added sugars to less than 10% of an individual’s total calorie consumption as part of a healthy diet and added-sugar intake to less than 5% (approximately 25 g [6 teaspoons] per day) of the total calorie consumption is healthier.13,14 A key plank of health education guidance is to raise public awareness of “hidden” sugars, salt, and fats, found in processed foods and sugar-sweetened beverages (SSBs), and support individuals to change behaviors to minimize these in their diets.1 Alongside health education, multiple recent studies have found that increased taxation on SSBs improved overall health status, particularly oral health.15–19 Oral diseases are the most frequently suffered non-communicable diseases (NCDs), causing morbidity and, in some cases, mortality in all age groups across the world.20 The 2016 Global Burden of Disease Study estimated that around 50% of the world’s population (3.58 billion) has dental caries.20 Oral health is not only affected by over-consumption of sugars but also by tobacco and alcohol use and poor diet, all of which are risk factors for the four leading NCDs: cardiovascular diseases (CVDs), cancer, chronic respiratory diseases, and diabetes. The complex interaction of various risk factors on health is not yet fully understood, but there are links, for example, an increase in type 2 diabetes is linked to an increase in periodontitis.20–22

However, certain strategies are making headway in tackling the impact of SSBs on human health. For example, an Australian study showed that a 20% increase in tax on SSBs saved A$666 million from the healthcare budget by preventing or reducing 3.9 million decayed, missing, and filled teeth (DMFT).14 Another Dutch study has found that a 20% levy on SSBs resulted in an average of 2.13 (95% uncertainty interval [UI] 2.12–2.13) caries-free tooth years per person, and on a population level, prevention of 1,030,163 (95% UI 1,027,903–1,032,423) decayed and lost teeth. From the cost-benefit perspective, the implementation of new levy on SSBs cost €37.3 million but generated an additional €3.49 billion in revenue and saved €159.01 million (95% UI 158.67–159.35) in healthcare expenditure on dental care.2

This rapid narrative review focuses specifically on SSBs and the effect of their consumption on human health, bringing together some of the key issues identified in literature, highlighting that this is a global health concern and noting strategies employed to reduce consumption of SSBs. Multiple studies have reported that the consumption of SSBs leads to several adverse health conditions such as obesity, type 2 diabetes mellitus, hypertension, and hypertriglyceridemia,23–25 and, therefore, it has become a major public health issue. This article considers the effects of consuming SSBs on general health and nutrition, including the oral microbiome and oral health. The key issues identified include patterns of consumption of SSBs, the general impact on human health and nutrition, specific effects on oral health and the oral microbiome, and strategies to address over-consumption.

MATERIALS AND METHODS

This rapid narrative review aimed to identify key topical issues, concerns, and strategies, rather than provide a comprehensive systematic review and meta-analysis. This study was conducted between March and June 2019. EBSCO, PubMed, and SCOPUS databases were searched, using the following search terms: “effects, sugar-sweetened beverages, consumption, tax, human oral microbiome, oral health, antibiotics, antimicrobials, microbial resistance, mortality, morbidity, increased healthcare costs, global health, and importance.” Google and Google Scholar were also used to identify other freely available literature. Relevant journals identified were hand-searched, and references were scanned to identify further articles.

SUGAR-SWEETENED BEVERAGES: DEFINITIONS AND CONSUMPTION

The number and variety of SSBs have grown over the last 20 years, and they are defined in different ways. Three definitions, representative of the wider definitions of SSBs, are set out here. The Department of Health, US State of Rhode Island, defines SSBs as “drinks with added sugar including non-diet soft drinks/sodas, flavored juice drinks, sports drinks, sweetened tea, coffee drinks, energy drinks, and electrolyte replacement drinks.”26 The WHO defines free sugar as “all monosaccharides and disaccharides added to foods by the manufacturer, cook, or consumer, plus sugars naturally present in honey, syrups, and fruit juices.”27 SSBs contain a very high amount of sugar,26,28 including highly cleaned crystalline white sugar, high-fructose corn syrup (HFCS), and other high-energy-yielding sugary compounds. The Cancer Council of Australia defines SSBs as “all non-alcoholic water-based beverages with added sugar, including sugar-sweetened soft drinks and flavored mineral waters, fortified waters, energy and electrolyte drinks, fruit and vegetable drinks, and cordials. This term does not include milk-based products, 100% fruit juice, or non-sugar sweetened beverages.”29 Finally, the US Departments of Health and Human Services and Agriculture take the view that SSBs are any liquids that are sweetened with various forms of added sugars such as brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, HFCS, honey, lactose, malt syrup, maltose, molasses, raw sugar, and sucrose.30 Examples include regular soda (not sugar-free), fruit drinks, sports drinks, energy drinks, sweetened waters, and coffee and tea beverages with added sugars.30

The overall global consumption of SSBs is very high and increasing. For example, a study conducted in the rural areas of South Africa has found that the consumption of SSBs increased by two-fold among men over 5 years,31 and another national cross-sectional study of children aged ≥2–9 years in the United States has found that consumption of SSBs increased by 135% between 1977 and 2001.32 In terms of overall consumption, a systematic review and meta-analysis comprising 193 national or sub-national studies in 187 countries, including over half of the world’s population and reflecting typical diet patterns, concluded that globally a high amount (8-oz. servings/day) of SSBs are consumed.33 However, there are differences between countries and regions, and this study identified that consumption of SSBs was the highest in the Caribbean countries (1.9, 95%CI: 1.2, 3.0 servings/day); fruit juice intake was the highest in Australia and New Zealand ranged from 0.66 [(95%UI: 0.36, 1.13) servings/ day to 0.013 (95%UI: 0.011, 0.017) servings/day]; and milk consumption was the highest in Central Latin America (1.06, 95%UI: 0.68, 1.59 servings/day). Consumption of SSBs, fruit juice, and milk was the lowest in East Asia and Oceania.33 Internationally and within regions, SSBs’ consumption is the highest among young people; fruit juice drinking had little correlation with age, and milk consumption was the highest in older people.33 These findings are supported by other studies. For example, another global study found that children and young people have a higher consumption of SSBs,34 and a US study found that children and adolescents obtained 10–15% of their total calorie consumption from SSBs and 100% fruit juices.35 In some countries, sugar is added to food and drinks; for example, a recent study found that in the United States, 74% of the 85,451 available palatable foodstuffs were supplemented with extra sugars.36

While the consumption of SSBs is high around the world, their consumption, and the subsequent effect on health, varies, and is dependent on a complex interaction between familial factors, ethnicity, lower socioeconomic status, income, access to education, and level of occupation.37,38 A cross-sectional study utilizing data from the population-based “Water Campaign” study aimed to assess the correlation between familial factors, ethnic background, and children’s SSBs’ utilization and found that a child’s age, parents’ emotional standing, child-rearing practices, and parental role-modeling were strongly associated with the child's SSBs consumption.39 More specifically, the accessibility of SSBs at home and school, parent’s consumption of SSBs, and their approach to diet were strongly related to a child's SSBs daily intake, with ethnic variations ranging from 8.7% for children of Moroccan or Turkish ethnicity to 44.4% for Dutch children.39 A survey of 990 parents and their adolescent children found that 31% of adolescents had SSBs ≥1 time/day, and 43.2% of parents consumed SSBs ≥2 times/day. The survey further found that the children’s consumption was strongly related to their parent’s SSBs intake and not their knowledge of health risks, with the adolescents’ SSBs consumption of ≥1 time/day being related to their parents’ consumption of ≥2 times/day (adjusted odds ratio [aOR] = 3.30; 95% confidence interval [CI] = 1.62–6.74).40 The knowledge of adolescents and parents about the link between SSBs consumption and health issues ranged from 60.7 to 80.4%: in terms of weight increase, 75.0 and 80.4% respectively; diabetes, 60.7 and 71.4% respectively; and dental caries, 77.5 and 72.9% respectively.40 There is also a strong link between people’s place of residence and predominant lifestyle factors. For example, the aOR of drinking SSBs ≥1 time/day was higher among Hispanics (aOR = 1.65) than the US-born non-Hispanic whites41; however, comparing individuals who had lived in the United States for <5 years, the adjusted odds of drinking SSBs ≥1 time/day was higher among adults who had lived in the United States for 5 to <10 years (aOR = 2.72), individuals who had lived in the United States for 10 to <15 years (aOR = 2.90), and individuals who had lived in the United States for ≥15 years (aOR = 2.41).41

SUGAR AND HUMAN HEALTH

Sugar is one of the main determinants of poor health, although public understanding of the long-term adverse effects of sugars (both overt and hidden) remains poor. Over-consumption of sugar causes many public health issues, including diabetes, obesity, hypertension, and chronic kidney diseases.42 Humans have consumed an increasingly higher amount of sugar as part of their diet over the last 160 years.43 The amount of sugar intake has tripled because of the promotion of fast (junk) food, processed food, and SSBs.42 Very high amounts of sugar are found in SSBs, sugary snacks, candy, chocolate, sweets, and even in children’s milk,44,45 with food manufacturers often adding 10 categories of sugars into factory-made foods.42 These added sugars include glucose, dextrose, fructose, HFCS, everyday sugar (sucrose), malt sugar (maltose), maltodextrin, and sugars found in honey, syrups, fruit juices, and fruit juice concentrates.42 The food industry uses approximately 56 different names for sugar and consumers therefore often do not realize that many foods include added sugars.42,46,47 This is particularly true for highly manipulated, “ultra-processed” foods (described in the NOVA [a name, not an acronym] Classification as Class 4), including SSBs, sweet and savory snacks, processed meat products, ice-cream, and many frozen ready meals, all of which include high levels of sugars, preservatives, saturated fats, and salts.48

Sugar-Sweetened Beverages and their Effects on Health

SSBs are widely marketed and sold all over the world, but they are ultra-processed and provide a devastatingly high sugar load that human physiology struggles to handle, with many adverse metabolic consequences.49 Sugar (like alcohol) acts more like a drug than a food, and every drug has the potential to cause harm as opposed to benefit, especially when taken in excess.50 A drug is described as “a chemical substance used in the treatment, cure, prevention, or diagnosis of a disease, or used to otherwise enhance physical or mental well-being.”51 The US drug authority defines a drug as “(i) any substance recognized in the official pharmacopeia or formulary of the nation; (ii) any substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in humans or other animals; (iii) any article, other than food, intended to affect the structure or any function of the body of humans or other animals; (iv) any substance intended for use as a component of such a drug, but not a device or a part of a device.”51 Ingesting high amounts of sugar via SSBs and ultra-processed foods may lead to overdose-related adverse reactions and harm, particularly because sugar generates reactive oxygen-carbon (ROC).52–54 SSBs are high in sugar but do not provide other nutrients such as fiber, vitamins, minerals, and other essential nutrients from plant sources that neutralize oxidative stress-induced ROC.55–58 The high amount of sugar in SSBs generates much more ROC than the available antioxidant level, which could lead to atherosclerosis, hypertension, peripheral vascular disease, coronary artery disease, cardiomyopathy, heart failure, and cardiac arrhythmias.58

In addition to these general health implications from sugar, other harmful effects have been reported. One review article has reported dependable evidence for the adverse effects of SSBs on children’s and teenagers’ health.4 This study revealed that weight gain and obesity, dental caries, insulin resistance, and caffeine-associated effects are often observed with the consumption of SSBs.4 Caffeine is well-known for its addictive and dependence potential and can increase the consumption of SSBs containing caffeine in comparison to non-caffeinated SSBs.59 High consumption of caffeine can lead to sleep disorders, headaches, stress, depressive symptoms, and suicidal ideation, and can increase the possibility of cigarette, marijuana, and drug addiction.4 Aside from the side-effects of caffeine, multiple systematic reviews and meta-analyses have found a positive correlation between the consumption of SSBs (particularly those high in calories) and weight gain, obesity, and metabolic syndrome.5–12 The proportion of SSBs as part of overall liquid intake also influences health. A high intake of SSBs lowers the consumption of milk, calcium (Ca2+), and essential nutrients. This increases the risk of medical complications, including diabetes.6,9,12,33,60,61 For example, an 8-year prospective research study of 91,249 nurses confirmed a statistically significant (P ≤ 0.001) relationship between an excessive intake of SSBs (more than three cans of cola or 450 calories per week) with the development of obesity and type 2 diabetes.61,62 Another study of diabetic adults found that consuming SSBs ≥1 time/day was more prevalent among individuals who had shorter span of diabetes (≤5 years: Prevalence Ratio [PR] = 1.47; 6–10 years: PR = 1.33 vs. ≥11 years), self-checked their glucose less often (≥0 to <1 time/day: PR = 1.69; ≥1 to <3 times/day: PR = 1.43 vs. ≥3 times/day), and had not undertaken a self-administration of diabetes course (PR = 1.25 vs. yes).63

High consumption of SSBs can also lead to a reduction of bone mineral compactness and subsequent fractures.64,65 For example, a cross-sectional study of 460 physically active teenage girls has found a high correlation (Odds Ratio [OR] = 4.94; 95% CI: 1.79, 13.62; P = 0.002) between bone fractures and SSBs intake.64 Another study amongst teenage girls has reported that the frequent consumption of SSBs was negatively associated with bone mineral content (BMC) (Pearson correlation coefficient, r = −0.256, P = 0.03) and decrease in Ca2+ (r = −0.227, P = 0.05).64 One explanation for this is that because drinking SSBs is associated with reduced milk consumption in both sexes (boys: r = −0.343, P = 0.01; girls: r = −0.244, P = 0.08),65 their overall diets might be lacking in Ca2+ and vitamins, which could contribute to poor bone health.

The Role of Added Sugars in Appetite Regulation

As discussed above, the high consumption of SSBs can lead to dietary imbalances with adverse health consequences, but some drinks may also more directly affect the appetite for more nutritious foods. For example, a randomized crossover study has found that temporary food intake (FI) was reduced after drinking chocolate milk (15%; P < 0.001) and cola (11%; P = 0.02) contrasted with water control.66 However, the total calorie consumption (beverage [kcal] + test meal [kcal]) was not influenced by the beverage category. Chocolate milk and cola moderated food intake in adolescent females, although 100% (unfortified) fruit juice did not, while the aggregate food intake did not alter between different plan treatments to minimize SSBs.66 Another study amongst adolescent males demonstrated a reduction in food intake (P < 0.001) after cola (940 ± 46 kcal) and chocolate milk (878 ± 41 kcal) contrasted with water control (1,048 ± 35 kcal) and after chocolate milk contrasted with an organic drink product (1,005 ± 44 kcal). The aggregate food intake after the organic product drink was higher than water control (1,159 ± 44 vs. 1,048 ± 35 kcal; P = 0.03).67 Normal appetite was not influenced by the treatment. However, the cola consumption led to a higher total food intake (P = 0.04) and a reduction in nutrients (P = 0.004) compared to the organic drink product.67 In this study, chocolate milk and cola reduced the next-supper food intake by 60 min, while drinks made from natural products expanded the aggregate food intake (refreshment + next meal) by more than 60 min, concluding that drink synthesis is a significant determinant of reduction in food intake.67

Addictive Properties of Sugar and Sugar-Sweetened Beverages

As described above, sugar has many properties of a drug, and multiple studies have reported that people could become addicted to sugar in a similar way as becoming addicted to cocaine, nicotine, alcohol, tobacco, or caffeine.68–73 The attraction of sugar is therefore much more than its sweet taste.42,74 The American Psychiatric Association defines addiction as “a complex condition, a brain disease that is manifested by compulsive substance use despite harmful consequence.”72 An addicted person is highly motivated to consume a “certain substance(s), such as alcohol or drugs, to the point that it takes over their life.”72 Addiction includes both psychological and physiological needs, and therefore any intervention has to focus on these aspects, exploring the underpinning issues that lead someone to over-consume substances detrimental to their health as well as helping them find ways to compensate for the physiological need. The term “addiction” is frequently used interchangeably with the word “dependence.”73,74 For example, drug dependence is categorized by obsessive, from time to time irrepressible, activities that happen at the cost of other events and strengthen with frequent access to the substance of abuse.68 The addict develops physical dependence as soon as the neurons become accustomed to repetitive drug exposure and then starts to work only in the presence of the substance of abuse. If the substance of abuse is stopped suddenly, many physiological responses arise, which could be mild to life-threatening.75 Sugar releases physiological endogenous opioids known as endorphins, which act to both relieve pain and promote short-term euphoria (a “sugar high”).76,77 As long-term over-consumption of sugars (e.g., of SSBs and industry-processed foods with high sugar content) leads to neurochemical adaptations that imitate the properties of opiates, this could lead to both psychological and physical dependence, and withdrawal signs and symptoms among people who stop or reduce their sugar consumption, particularly if this is sudden.68,78,79 For example, one study has reported that when young people stopped consumption of SSBs for 3 days, they developed a strong desire for SSBs, complained of headaches, reported a reduction in inspiration, happiness, and satisfaction, a failure to focus, and a lack of overall well-being.80

As with other addictions, although many people know well that consuming high sugary foods and drinks is unhealthy and could lead to life-threatening diseases,10,34,38,81–83 it can be difficult for them to stop. The addictive properties of sugar, much of which is “hidden” in processed foods and SSBs, mean that its impact on health is not often directly understood or addressed by consumers in spite of the evidence available. As we have noted, consumption of SSBs with high sugar content could contribute to obesity, type 2 diabetes, CVDs, and cardiometabolic diseases,84 and we now explore some of the more life-threatening effects of long-term and/or high consumption of SSBs.

SSBs and Cardiovascular Diseases

Multiple studies have reported that the frequent heavy drinking of SSBs (more than three cans of cola or 450 calories per week)13 is correlated with coronary heart disease (CHD) and adverse deviations in lipids, inflammatory factors, and leptin in both sexes.85–87 A US study involving 4,443 respondents has found a moderate positive correlation between the consumption of SSBs and dietary sodium intake (r = 0.35, P = 0.001).88 Using an unadjusted regression model, this study found that higher SSBs consumption was associated with a 12% increased dietary sodium intake, specifically a 45-g/day consumption of SSBs was associated with an additional 390-mg sodium (Na)/day (1-g salt/day; P = 0.001).88 Another study in Australia reported that a regular intake of SSBs was positively correlated with salt intake. (r = 0.35, P = 0.001), that each additional 1 g/day of salt was associated with a 30-g/day higher consumption of SSBs, and that salt intake alone is responsible for 11% increase in consumption of SSBs.89 Both these studies recommend that lower consumption of SSBs contributes to the recognized benefits of lowering salt intake, including blood pressure control and childhood obesity risk.88,89

A systematic review, comprising 12 studies involving 409,707 participants, found that a continuous longstanding intake of SSBs could lead to the development of hypertension and related CVDs.90 This finding is corroborated by other studies, reporting that a high consumption of SSBs (more than three cans of cola or 450 calories per week)13 correlates with the development and prevalence of hypertension,91 with a high low-density lipoprotein (LDL)–cholesterol level,92 and a low level of high-density lipoprotein (P < 0.0001).93 Another US study, conducted among 3,683 CHD patients over 22 years of follow-up, has reported that those who consumed the lowest (Q1) quartile of SSBs had a 20% greater relative risk of CHD than those in the highest (Q4) quartile (RR = 1.20, 95% CI: 1.09, 1.33, P < 0.01 [Relative Risk (RR) = 1.20, 95% CI: 1.09, 1.33, P< 0.01]) after adjusting for age, smoking, physical activity, alcohol, multivitamins, family history, diet quality, energy intake, body mass index (BMI), pre-enrollment weight change, and dieting.85 Another national US representative cross-sectional study of 4,867 young people aged between 12 and 18 years reported that consuming more SSBs was significantly (P = 0.01) correlated statistically to an increasing serum uric acid and systolic blood pressure (P = 0.03) but not related to obesity.94 The consumption of SSBs is also correlated with an increased danger of “total mortality; pooled hazard ratios (95% CI) across categories (<1/month, 1–4/month, 2–6/week, 1–<2/day, and ≥2/day) were 1.00 (reference), 1.01 (0.98, 1.04), 1.06 (1.03, 1.09), 1.14 (1.09, 1.19), and 1.21 (1.13, 1.28; P < 0.0001).”94 This study also reported correlation for “CVD mortality (hazard ratio comparing extreme categories was 1.31 (95% CL, 1.15, 1.50), P < 0.0001) and cancer mortality (1.16 [1.04, 1.29], P = 0.0004).”94

Artificial sweeteners, such as aspartame, sucralose, and saccharine, are generally used as sugar substitutes to reduce calories in many types of SSBs and are often seen as a better alternative.95 However, the consumption of artificially sweetened beverages is also correlated with total and CVD-related death rates when high amounts of SSBs are ingested.94 The ingestion of artificial sweeteners has been linked to adverse effects such as cancer, weight gain, metabolic disorders, prematurity, bronchial asthma, type 2 diabetes, and negative modification of gut microbiota activity.96–98

Although human food does not naturally contain high amounts of fructose, fructose-containing sugars (sucrose and high fructose corn syrup) are often added to SSBs and other factory-processed foods, primarily so that they taste sweeter and thus more palatable to modern western tastes.84 SSBs are a large part of this picture, with one study’s findings revealed that from 2011 to 2012, at least 46.3% of North American adult population consumed SSBs daily that yielded 213.0 kcal/day99; another study revealed that 54 kcal/day out of 83 kcal/day was obtained from SSBs.100 In the United States, on average, one can of SSBs provides 150 kcal and 40–50-g sugar in the form of HFCS, which corresponds to 10 teaspoons of sucrose.101 The consumption of SSBs in the United States in 24 years (1977–2001) has increased by 135%, which increased calorie intake by 83 kcal/day.32,100

SSBs and Fertility

The consumption of SSBs could also affect sexual health and fertility. Pre-pubescent girls who have a heavy consumption of SSBs reach menarche much earlier than girls who have low consumption,98,102 and pre-menarchal girls who consume more than 1.5 portions of SSBs daily have a 24% (95% CI: 13, 36%; P: <0.001) higher possibility of starting their menstrual periods in the next month than girls who consume less than or equal to two servings of SSBs weekly.102 Men’s SSBs consumption also affects their sexual health.103 Men who consume greater than or equal to 1.3 servings of SSBs per day have 9.8% (95% CI: 1.9, 17.8) units poorer “progressive sperm motility” than men who consume less than 0.2 serving of SSBs per day (P = 0.03).80 This correlation was statistically significant (P = 0.005) for sturdier and lean men, but no significant correlation (P = 0.98) was observed in obese men.80 Another study in US men aged 20–39 years has reported that a high SSBs intake is strongly correlated with low serum testosterone.104 In this study, multivariate logistic regression found that the OR of low testosterone was significantly higher statistically with a high rate of SSB drinks in Q4 (≥442 kcal/day vs. male participants in Q1, ≤137 kcal/day; aOR = 2.29, P = 0.041). Secondary risks of high consumption of SSBs also exist; for example, high consumption of SSBs without corresponding exercise could lead to obesity and high BMI; high BMI is in itself a risk factor for a low level of testosterone. It was found in one study that after adjusting for possible confounding variables, research respondents with BMI ≥ 25 kg/m2 had a lower testosterone level than those with BMI ≤ 25 kg/m2 (aOR = 3.68, P =0.044).104 Zero-calorie SSBs had little correlation with fecundability, thus indicating that the sugars are influential on fertility. High sugar intake can lead to obesity; for men, this could lead to hypotestosteronemia and impaired spermatogenesis, which reduce fecundability.105,106 Another study found that in both sexes the consumption of SSBs was strongly correlated with a reduced fecundability (fecundability ratio [FR] = 0.81; 95% CI: 0.70, 0.94, and 0.78 for females; 95% CI: 0.63, 0.95 for males, both consuming ≥7 SSBs per week compared to none for females and males respectively).105 Fecundability was further lowered in individuals who drank ≥7 servings of SSBs per week (FR = 0.75, 95% CI: 0.59, 0.95 for females and 0.67; FR = 0.67; 95% CI: 0.51, 0.89 for males) and adjusted FR (95%, CL) = 0.59 (0.28, 1.28).105

Sugar-Sweetened Beverages and Nutrition

Constant and high consumption of SSBs can affect the overall quality of a diet and lead to essential nutritional deficiencies,107,108 for example, reduction in the consumption of vegetables and fruits.109 One systematic review and meta-analysis comprising 88 articles reported a clear association between the high consumption of SSBs (with a corresponding high intake of sugars, fructose, and sucrose) and a reduced consumption of milk, Ca2+, and other essential nutritional components, including vitamins, minerals, protein, fats, water, and carbohydrates, and a higher risk of medical complications.107 This study also found that reduction in the intake of SSBs by 16 oz. daily correlated with the increased consumption of around 4 oz. of milk daily.107 Additionally, this study reported other research that found a significant association between high consumption of SSBs and a low intake of milk and dairy products. A total of 24 studies108,110–127 have revealed that consumption of high amount SSBs was significant related with low intake of milk and dairy products as well as Ca2+.Another study has estimated that the negative impact of SSBs consumption on milk and Ca2+ intake was –0.21 (P < 0.001; Q5 = 23.09, P < 0.001) and –0.13 (P < 0.001; Q4 = 15.22, P = 0.004) respectively.107

High SSB consumption’s significant correlations (Pearson correlation coefficient’s r-value) with additional sugar, fructose, and sucrose were 0.18, 0.36, and 0.23 respectively.107 Other studies, including a meta-analysis, have report that consumption of SSBs increases the amount of carbohydrates in diet.62,111,114,115,128–136 High consumption of SSBs, coupled with an increase in carbohydrates other than pure sugars, could lead to obesity and increase the possibility of metabolic syndrome, type 2 diabetes, and hypertension.137,138 High consumption of sugars harms the mitochondria, consequently affecting age vitality and could result in a type of starvation (because of leptin and insulin obstruction), increasing appetite in some individuals.135 A high intake of SSBs is correlated to a reduced consumption of protein (r = –0.14), pure fruit juice (r = –0.17), fruit (r = –0.09), and riboflavin (r = –0.12).139 For increase of 1 can/day of SSBs consumption and 10 g/day increment in added sugar and fructose each, the log alanine aminotransferase (ALT) increased by 0.079 U/L (95% CI: 0.022, 0.137), 0.012 U/L (95% CI: 0.002, 0.022), and 0.031 U/L (95% CI: 0.012, 0.050), respectively, and the log aspartate aminotransferase (AST) increased by 0.029 U/L (95% CI: −0.011, 0.069), 0.007 U/L (95% CI: 0.000, 0.014), and 0.017 U/L (95% CI: 0.004, 0.030) respectively.140 Women who consumed ≥1.50 can/day (12-oz. can) of SSBs versus less intake had a 0.127 U/L (95% CI: 0.001, 0.254) higher ALT level (13.5% change; 95% CI: 0.1, 28.9) and a 0.102 U/L (95% CI: 0.015, 0.190) higher AST level (10.8% change; 95% CI: 1.5, 20.9).140 SSBs were also related to higher serum ALT and AST-fixation values among physically fit pre-menopausal women, demonstrating that even moderate ongoing consumption of SSBs could evoke hepatic lipogenesis.140 In general, there is no correlation (all RS < 0.01) between drinking SSBs and fat or vitamin, such as vitamins A and B12, intake.141

A systematic review and meta-analysis,142 comprising 30 and 38 randomized control trials and prospective cohort studies (PCS), respectively, have established that a reduction in the consumption of SSBs reduces body weight (0.80 kg, 95% CI: 0.39–1.21; P < 0.001) whereas increased SSBs consumption leads to a comparable weight increase (0.75 kg, 95% CI: 0.30–1.19; P = 0.001). Additionally, the meta-analysis found that children who consumed a higher amount of SSBs had a 55% (95% CI: 32–82%) greater risk of obesity compared to children who consumed less SSBs.142 Another meta-analysis, comprising eight PCS involving 310,819 research respondents and 15,043 patients of type 2 diabetes, has established that a daily intake of SSBs was associated with a 26% (95% CI: 12–41%) higher possibility of developing type 2 diabetes compared with an infrequent consumption of one SSB per month.9

The Effects of Caffeine

As mentioned above, caffeine is perhaps the most regularly consumed pharmacologically active ingredient globally. Caffeine (1,3,7-trimethylxanthine) is a natural alkaloid found in coffee beans, tea leaves, cocoa beans, cola nuts, and other plants, and is available in SSBs, chocolate, and cocoa. Women of reproductive age and growing children have been identified as more at risk of damage due to caffeine-containing drinks.143 This study suggested that caffeine consumption must be limited to a level of 300 mg/day, equivalent to 4.6 mg/kg body weight per day in 65-kg women who are planning to conceive or are pregnant. The maximum level of caffeine drink for children must be 2.5 mg/kg body weight per day to avoid the risk of caffeine-related adverse effects.143 Another study has reported that people who sleep for 5–6 h daily consume more caffeine-containing SSBs than those who sleep for 7–8 h; such variances were not detected for consumption of SSBs without caffeine.144 This study144 has additionally reported a dose-dependent association with the total consumption of SSBs, finding that there was a 21 and 11% more pronounced sleep disturbance effect during 5-h and 6-h sleep, respectively, in comparison to 7–8-h sleep.144

The Effects of Sugar-Sweetened Beverages on Oral Health

The importance of oral health to human health

The WHO defines oral health as “a state of being free from chronic mouth and facial pain, oral and throat cancer, oral infection and sores, periodontal (gum) disease, tooth decay, tooth loss, and other diseases and disorders that limit an individual’s capacity in biting, chewing, smiling, speaking, and psychosocial wellbeing.”145 Although the WHO declares that oral healthcare is a fundamental health right, access to dental care is often unavailable, particularly in poor and marginalized communities, and noticeable discrepancies and disparities in the management of dental-associated diseases have been reported in both low- and high-resource countries.20,136,146–150 Oral diseases are a critical public health issue around the world, affecting people of all age groups in high-income and low- and middle-income countries (LMICs), causing pain, distress, disfigurement, dental deformity, and even death.20,136,146–148 In 2016, the WHO reported that around 3.58 billion people frequently suffer from oral infectious and non-infectious diseases20; therefore, implementing good oral health is central to improving overall global health.147

Although treatment strategies for oral conditions are now very advanced, many of these are unavailable to communities who struggle for access to dental care in both high-income and LMICs.132 For example, in the United States, dental caries, periodontal diseases, tooth loss, dry mouth, oral cancer, chewing problems, pain, or discomfort among all age groups are the most poorly addressed public health issues, and these oral conditions are frequently associated with general health difficulties.150 Many LMICs have a major shortage of well-trained oral health professionals, and therefore in all countries better prevention policies and strategies are required so that the need for dental treatment is reduced.151 Health education and promotion activities for maintaining oral health and preventing oral diseases are needed in both LMICs and marginalized groups and poor communities in high-income countries.148 Such activities are to be underpinned by research to develop sustainable oral health policies and improve capacity-building around the world148 to promote better oral healthcare, which includes psychological factors as well as biomedical and clinical issues.152 Oral healthcare must consist of operational research studies aimed at developing a better understanding among health professionals for putting into practice the knowledge about biomedical and clinical science of oral diseases.153 Alongside this, educational interventions aimed at updating knowledge of both prevention and treatment strategies among healthcare professionals and other stakeholders are required.145

SSBs and oral health

As we have noted, SSBs have a very high sugar and acid content, and greatly contribute to dental caries and poor oral health in many countries, including the United States,154 South Korea,155 and Poland.156 This has been known for many years. For example, in the United States, the term “mountain dew mouth” was coined relating to an “epidemic” of oral disease among many children in the state of Kentucky. The children did not often brush their teeth because of gum inflammation and pain, had cavities and fillings, with some toddlers pulling out their own decaying teeth with pliers.154 The State had the highest percentage of the US population without teeth before attaining the age of 65 years.154 Such findings led to calls for excluding all SSBs from the diet to improve oral and general health. However, adherence to such a holistic approach was frequently low, hence there was a need to develop a range of flexible policies and strategies which could reflect local culture and practices.157

The special relationship with “oral health problems and diet and new-generation soft drinks, such as energy, sports drinks, and flavored waters is a real concern as these beverages are marketed as a beverage of choice for adolescents,”158 and are often seen as healthy. An Australian study of 3,671 teenagers found that consuming one cup or more of SSBs daily was consistently related to a higher odds of poorer oral health when compared with drinking less than 1 cup/day of diet soft drinks, sports drinks, flavored water, and energy drinks.159 Besides sugar, one of the main problems of SSBs is their acidity. SSBs, in general, have a pH level of 2.4–3.3160,161 or a pH below 4.162 The pH of the mouth cavity is 6.75–7.25,163 and that of saliva is 6.7–7.4.164 A pH below 6 leads to dentine erosions and carries formation starts when the pH level drops to 5.5.163 Sugars attach to the external enamel surface of the teeth, and the longer they are attached, the more opportunity microbes get to ferment sugar molecules to produce acid, which leads to dental caries.165–167 Furthermore, a low pH promotes the growth of aciduric microorganisms, such as Streptococcus mutans (and related species) and Lactobacillus species. These are not typically found, or only available in the sub-threshold level of dental plaque163,168,169 and are considered to have the highest impact on dental caries formation.170–173 Another study amongst adults in Poland156 aimed to determine the correlation between the intake of SSBs and oral fungal infection; 38% of the research respondents consumed an amount higher than the recommended SSBs (less than three cans of cola or 450 calories per week.61 68% of the Polish study population were infected with seven different types of Candida (Candida albicans, C. tropicalis, C. guilliermondii, C. famata, C. lusitaniae, C. humicola, and C. lipolytyca) in the oral cavity.156 There was a statistically significant correlation between the amount of fungal infections and consumption of SSBs with high sugars (correlation coefficient 0.5395), with 76.3% of those with high consumption of SSBs having infections.156 In addition, positive statistically significant correlations (P = 0.004; correlation coefficient 0.9691) were found with a high intake of coffee and tea with sugar, leading to the conclusion that added sugar promotes a significant escalation of fungal colonization in the oral cavity.156

SSBs are a principal source of added sugars among the US population.174 The US dietary guidelines recommend that below 10% of total calorie intakes are derived from pure crystalline sugar175; nonetheless, most of the US population has a much higher intake of sugar.174–178 As with the general population, the high consumption of SSBs has a negative impact on children’s general and oral health,179–183 and the consumption of milk is significantly reduced. Milk is considered as the primary resource of Ca2+, K+, vitamin D among US children and adolescents184–186 and a lack of these impacts on not only oral health (e.g., caries and oral diseases187) but also leads to low bone mass and density, fractures and minor injuries.188,189 Another US study conducted among children between 8 and 9 years of age found that they regularly consumed around two servings (average preserving SSBs 140–150 calories and 35–37.5 g of sugar per 12-oz. serving)34 of SSB daily (1.7, 95% CI: 1.6–1.8) and 52% suffered from oral and dental diseases.190 After adjusting for population-related and parental factors (in particular the mothers’ oral health), this study found a 22% adjusted PR = 1.2, 95% CI: 1.1, 1.3 increase in the possibility of caries for every additional consumption of SSB daily190 and recommended a restriction on SSBs consumption to reduce dental diseases, obesity, and to promote overall better health. A Finnish study found a positive correlation in 4-year old children between SSBs consumption and an augmented proportion of DMFT, but no significant association with socio-demographic and behavioral profiles.191 In adults, the consumption of 1–2 and 3+ SSBs per day, compared with those not consuming any SSBs, had a 31% incidence rate ratio (IRR): 1.31; 95% CI: 1.02–1.67 and 33% IRR: 1.33; 95% CI: 1.03–1.72 increase in DMFT respectively, concluding that there is a positive dose-response relationship between dental and oral diseases and the consumption of SSBs. The high occurrence and frequency of oral diseases in American children (for example, one study found that 51% of the US children aged 6–11 years had oral and dental infectious diseases192) has made it a public health concern as dental caries often cause other health issues such as tooth loss, poor quality of life, impairs mastication and digestion, and/or promotes infectious diseases that could lead to death.193,194

Effects of sugar-sweetened beverages on oral microbiome

The health status of the oral cavity often represents an individual’s overall health.195 The human oral cavity is normally inhabited by abundant and disparate microbes of bacterial, viral, and fungal species,196,197 variously termed as oral microflora, oral microbiota, or the oral microbiome.198–200 Every one or two hours, every person’s mouth develops almost six billion new microbial communities.201,202 The word “microbiome” was coined by Dr. Joshua Lederberg as “the ecological community of commensal, symbiotic, and pathogenic microorganisms that literally share our body space and have been all but ignored as determinants of health and disease.”203 The microbiome plays a vital role in building the human immune system, helps prevent the growth of pathogenic microbes, and contributes in maintaining health and combating disease.204–210

The human oral microbiome is a highly researched area and plays a dynamic responsibility in the conservation of oral health.211 It contains a total of 770 species, which include: officially named (57%), yet not named but cultivable (13%), and uncultivated (30%) phylotypes.212 A diet containing a high level of carbohydrates (and high sugar content) has the highest impact on the oral ecological microbial community,213–215 and multiple studies have reported that the consumption of sugary foods stimulates acidogenic and aciduric microorganisms to flourish, particularly lactobacilli and Streptococcus mutans present in SSB consumers’ mouth cavities, which are highly associated with the development of dental caries.107,213,216–222

STRATEGIES FOR REDUCING CONSUMPTION OF SSBS

The consumption of SSBs contributes to the development of several long-term, life-limiting conditions. This has enormous implications on public health in both low- and high-resource settings, and requires strong public health interventions.223,224 As noted, many recent studies have highlighted that the consumption of SSBs is correlated with the development of obesity, dental caries, type 2 diabetes, insulin resistance, CVDs, and sexual health.4,85–87,98,103,104,128,223 Several public health strategies, including health education and promotion, have been employed to address the issues raised by the addition of sugar and other products to foods and beverages. Alongside these, various governments have tried through legislative and taxation controls to limit the addition of unnecessary ingredients. The notion of additional levies on food and drinks to preserve and promote public health dates back to 1776, when the Scottish economist, philosopher, author and “father of economics,” Adam Smith wrote one of his two classic works An Inquiry into the Nature and Causes of the Wealth of Nations.” In this essay, the author promoted imposing additional levies on tobacco, rum, and sugar as none of these products was considered essential for life.141,225

However, more recently, multiple studies also have demonstrated that imposing levies or duties on SSBs and unhealthy foods is successful in reducing their consumption, thus helping to improve public health.226–230 A recent systematic review found that not only was consumers’ intended consumption of SSBs significantly reduced when tax on them were increased but consumers also reported an intention to buy healthy beverages instead thus reducing calorie and sugar intake.231 Another systematic review concluded that an additional levy on SSBs is an effective policy and has the potential to cut SSBs’ drinking.232 Furthermore, this review has found that while additional duty on SSBs reduces their consumption in both high- and low-income groups, it has a greater positive effect among the low-income group,232 which in turn would improve the overall health of the population. A study conducted in Berkeley, CA, USA has found that after 1 year of implementation, SSBs’ sales came down and their excise levy was achievable. Although the research was inconclusive as to whether the fall in sales of SSBs was due to the increased price or other health-related promotional programs,233 a follow-up study in the same location found that after 3 years of implementing a higher levy, there was a sustained reduction in SSBs consumption.234

Following these findings and, as a response to the rise in obesity and other non-communicable health conditions, several countries in the last decade have introduced high levies on SSBs and unhealthy foods, especially those containing high salt, fat, and/or sugar.225 These countries include Mexico,235,236 France, Hungary, Finland, Latvia,237 Barbados, Belgium, Brunei Darussalam, Chile, Kiribati, Norway, Samoa, Saudi Arabia, Spain, Vanuatu, Mauritius, French Polynesia,238 Fiji and Tonga, Samoa, Nauru,239 South Africa,240,241 and the United Kingdom.242 The marketing strategies of SSBs are being monitored strictly using regulatory measures. It has been suggested specifically that television and Internet advertising of SSBs should be controlled, as very aggressive advertising influences their increased usage, particularly among children and young people.240 Any controls on the sales and advertising of SSBs should be a part of national strategy about food and nutrition, because well-planned and implemented food policies can have a huge impact on improving the diets (and thus the health) of individuals and communities.243 Policymakers must involve community representatives and leaders and consider behavioral, socioeconomic, and demographic factors relating to specific communities to develop meaningful customized food policies.244

CONCLUSIONS

The provision of healthy and safe food is vital for human health, and the addition of unnecessary sugars in foodstuffs is an important global issue, leading to multiple long- and short-term health issues and spiraling costs for both individuals and governments. Compelling evidence indicates that the regular consumption of SSBs has a significant adverse impact on people’s health. The worldwide demand of SSBs has proliferated over the last decades, spurred on by intensive marketing and promotion by global corporations. There is an urgent need, therefore, to develop strategies to ensure public safety by reducing the consumption of SSBs and other foods with high sugar content. A combination of policy and strategic approaches is required, including health education and promotion about the risks of consuming SSBs for parents and children in schools and other institutions, thus encouraging change in individual behavior; limiting access of vulnerable groups to SSBs; promoting and giving access to oral healthcare; lobbying governments, interest groups, and large corporations; and legislation and taxation.

Recommendations

The following recommendations are put forward:

Key Findings

AUTHOR CONTRIBUTIONS

MH, JM, and MS were responsible for the conceptualization and methodology of the study. MH, JM, MS, NS, SZH, and MAB made contributions to the original draft preparation, supervised the study and were responsible for project administration. MH, JM, and MS reviewed and edited the article.

CONFLICTS OF INTEREST

The authors declare no conflicts of interest.

FUNDING

This review manuscript received no financial support.

ACKNOWLEDGMENTS

The principal authors are very grateful to the UPNM library for its support in providing the manuscripts which are not part of open access.

REFERENCES

  1. World Health Organization (WHO). Health diet, 2018 [Internet]. Available at: https://www.who.int/news-room/fact-sheets/detail/healthy-diet.
  2. Mozaffarian D, Ludwig DS. The 2015 US dietary guidelines: Lifting the ban on total dietary fat. JAMA 2015;313(24):2421–2. https://doi.org/10.1001/jama.2015.5941
  3. Kromhout D, Spaaij CJ, de Goede J, Weggemans RM. The 2015 Dutch food-based dietary guidelines. Eur J Clin Nutr 2016;70(8):869–78. https://doi.org/10.1038/ejcn.2016.52
  4. Bleich SN, Vercammen KA. The negative impact of sugar-sweetened beverages on children's health: An update of the literature. BMC Obes 2018;5:6. https://doi.org/10.1186/s40608-017-0178-9
  5. Luger M, Lafontan M, Bes-Rastrollo M, Winzer E, Yumuk V, Farpour-Lambert N. Sugar-sweetened beverages and weight gain in children and adults: A systematic review from 2013 to 2015 and a comparison with previous studies. Obes Facts 2017;10(6):674–93. https://doi.org/10.1159/000484566
  6. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gaIn: A systematic review. Am J Clin Nutr 2006;84(2):274–88. https://doi.org/10.1093/ajcn/84.2.274
  7. Malik VS, Willett WC, Hu FB. Sugar-sweetened beverages and BMI in children and adolescents: Re-analyses of a meta-analysis. Am J Clin Nutr 2009;89(1):438–9. https://doi.org/10.3945/ajcn.2008.26980
  8. Zheng M, Allman-Farinelli M, Heitmann BL, Rangan A. Substitution of sugar-sweetened beverages with other beverage alternatives: A review of long-term health outcomes. J Acad Nutr Diet 2015;115(5):767–79. https://doi.org/10.1016/j.jand.2015.01.006
  9. Hu FB, Malik VS. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: Epidemiologic evidence. Physiol Behav 2010;100:47–54. https://doi.org/10.1016/j.physbeh.2010.01.036
  10. Malik VS, Popkin BM, Bray GA, Després JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: A meta-analysis. Diabetes Care 2010;33(11):2477–83. https://doi.org/10.2337/dc10-1079
  11. Bucher Della Torre S, Keller A, Laure Depeyre J, Kruseman M. Sugar-sweetened beverages and obesity risk in children and adolescents: A systematic analysis on how methodological quality may influence conclusions. J Acad Nutr Diet 2016;116(4):638–59. https://doi.org/10.1016/j.jand.2015.05.020
  12. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: A systematic review and meta-analysis. Am J Clin Nutr 2013;98(4):1084–102. https://doi.org/10.3945/ajcn.113.058362
  13. World Health Organization. Diet, nutrition, and the prevention of chronic diseases: Report of a Joint WHO/FAO Expert Consultation. WHO Technical Report Series, No. 916 (TRS 916). Geneva: World Health Organization; 2003. Available at: https://www.who.int/dietphysicalactivity/publications/trs916/en/
  14. World Health Organization. Information note about intake of sugars recommended in the WHO guideline for adults and children. Geneva: WHO Press, World Health Organization; 2015. Available at: https://www.who.int/nutrition/publications/guidelines/sugar_intake_information_note_en.pdf
  15. Sowa PM, Keller E, Stormon N, Lalloo R, Ford PJ. The impact of a sugar-sweetened beverages tax on oral health and costs of dental care in Australia. Eur J Public Health 2019;29(1):173–7. https://doi.org/10.1093/eurpub/cky087
  16. Jevdjevic M, Trescher AL, Rovers M, Listl S. The caries-related cost and effects of a tax on sugar-sweetened beverages. Public Health 2019;169:125–32. https://doi.org/10.1016/j.puhe.2019.02.010
  17. Lal A, Mantilla-Herrera AM, Veerman L, et al. Modelled health benefits of a sugar-sweetened beverage tax across different socioeconomic groups in Australia: A cost-effectiveness and equity analysis. PLoS Med 2017;14(6):e1002326. https://doi.org/10.1371/journal.pmed.1002326
  18. Saxena A, Koon AD, Lagrada-Rombaua L, Angeles-Agdeppa I, Johns B, Capanzana M. Modelling the impact of a tax on sweetened beverages in the Philippines: An extended cost-effectiveness analysis. Bull World Health Organ 2019;97(2):97–107. https://doi.org/10.2471/BLT.18.219980
  19. Saxena A, Stacey N, Puech PDR, Mudara C, Hofman K, Verguet S. The distributional impact of taxing sugar-sweetened beverages: Findings from an extended cost-effectiveness analysis in South Africa. BMJ Glob Health 2019;4(4):e001317. https://doi.org/10.1136/bmjgh-2018-001317
  20. World Health Organization. Oral health. Key facts. 2018. Available at: https://www.who.int/news-room/fact-sheets/detail/oral-health
  21. Taylor GW, Borgnakke WS. Periodontal disease: Associations with diabetes, glycemic control, and complications. Oral Dis 2008;14(3):191–203. https://doi.org/10.1111/j.1601-0825.2008.01442.x
  22. Sanz M, Ceriello A, Buysschaert M, et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. J Clin Periodontol 2018;45(2):138–49. https://doi.org/10.1111/jcpe.12808
  23. Gui ZH, Zhu YN, Cai L, et al. Sugar-sweetened beverage consumption and risks of obesity and hypertension in Chinese children and adolescents: A national cross-sectional analysis. Nutrients 2017;9(12):1302. https://doi.org/10.3390/nu9121302
  24. He B, Long W, Li X, Yang W, Chen Y, Zhu Y. Sugar-sweetened beverages consumption positively associated with the risks of obesity and hypertriglyceridemia among children aged 7–18 years in South China. J Atheroscler Thromb 2018;25(1):81–9. https://doi.org/10.5551/jat.38570
  25. Yoshida Y, Simoes EJ. Sugar-sweetened beverage, obesity, and type 2 diabetes in children and adolescents: Policies, taxation, and programs. Curr Diab Rep 2018;18(6):31. https://doi.org/10.1007/s11892-018-1004-6
  26. The Department of Health, the State of Rhode Island. Sugar-sweetened beverages. 2019. Available at: http://www.health.ri.gov/healthrisks/sugarsweetenedbeverages/
  27. Mann J. The science behind the sweetness in our diets. Bull World Health Organ 2014;92(11):780–1. https://doi.org/10.2471/BLT.14.031114
  28. Amount of sugar in different drink categories. Available at: http://www.moh.gov.bn/SiteCollectionDocuments/SSBS/Amount%20of%20sugars%20in%20SSBS.pdf
  29. Cancer Council of Australia. Position statement—Sugar-sweetened beverages. National Cancer Control Policy. Available at: https://wiki.cancer.org.au/policy/Position_statement_-_Sugar-sweetened_beverages
  30. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2015–2020. 8th ed. Washington, DC: U.S. Government Printing Office; 2015. External. Available at: https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf
  31. Vorster HH, Kruger A, Wentzel-Viljoen E, Kruger HS, Margetts BM. Added sugar intake in South Africa: Findings from the adult prospective urban and rural epidemiology cohort study. Am J Clin Nutr 2014;99(6):1479–86. https://doi.org/10.3945/ajcn.113.069005
  32. Nielsen SJ, Popkin BM. Changes in beverage intake between 1977 and 2001. Am J Prev Med 2004;27(3):205–10. https://doi.org/10.1016/j.amepre.2004.05.005
  33. Singh GM, Micha R, Khatibzadeh S, et al. Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: A systematic assessment of beverage intake in 187 countries. PLoS One 2015;10(8):e0124845. https://doi.org/10.1371/journal.pone.0124845
  34. Malik VS, Popkin BM, Bray GA, Després JP, Hu FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation 2010;121(11):1356–64. https://doi.org/10.1161/CIRCULATIONAHA.109.876185
  35. Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988–2004. Pediatrics 2008;121(6):e1604–14. https://doi.org/10.1542/peds.2007-2834
  36. Ng SW, Slining MM, Popkin BM. Use of caloric and noncaloric sweeteners in US consumer packaged foods, 2005–2009. J Acad Nutr Diet 2012;112(11):1828–34.e6. https://doi.org/10.1016/j.jand.2012.07.009
  37. Mazarello PV, Hesketh K, O'Malley C, et al. Determinants of sugar-sweetened beverage consumption in young children: A systematic review. Obes Rev 2015;16(11):903–13. https://doi.org/10.1111/obr.12310
  38. Wattelez G, Frayon S, Cavaloc Y, Cherrier S, Lerrant Y, Galy O. sugar-sweetened beverage consumption and associated factors in school-going adolescents of New Caledonia. Nutrients 2019;11(2):452. https://doi.org/10.3390/nu11020452
  39. van de Gaar VM, van Grieken A, Jansen W, Raat H. Children’s sugar-sweetened beverages consumption: Associations with family and home-related factors, differences within ethnic groups explored. BMC Public Health 2017;17(1):195. https://doi.org/10.1186/s12889-017-4095-0
  40. Lundeen EA, Park S, Onufrak S, Cunningham S, Blanck HM. Adolescent sugar-sweetened beverage intake is associated with parent intake, not knowledge of health risks. Am J Health Promot 2018;32(8):1661–70. https://doi.org/10.1177/0890117118763008
  41. Park S, Blanck HM, Dooyema CA, Ayala GX. Association between sugar-sweetened beverage intake and proxies of acculturation among U.S. Hispanic and non-Hispanic white adults. Am J Health Promot 2016;30(5):357–64. https://doi.org/10.1177/0890117116646343
  42. Mustapha K. Sweet kills: How overconsumption of sugar is making Malaysians obese, sick. New Straits Times, New Straits Times Press (M) Bhd. A part of Media Prima Group, Malaysia; 2019. Available at: https://www.nst.com.my/lifestyle/heal/2019/04/482092/sweet-kills-how-overconsumption-sugar-making-malaysians-obese-sick
  43. Health Line. 11 Graphs That Show Everything That is Wrong with The Modern Diet. Nutrition. 2019. Available at: https://www.healthline.com/nutrition/11-graphs-that-show-what-is-wrong-with-modern-diet#section10
  44. Bailey RL, Fulgoni VL, Cowan AE, Gaine PC. Sources of added sugars in young children, adolescents, and adults with low and high intakes of added sugars. Nutrients 2018;10(1):102. https://doi.org/10.3390/nu10010102
  45. Smith RD, Cornelsen L, Quirmbach D, Jebb SA, Marteau TM. Are sweet snacks more sensitive to price increases than sugar-sweetened beverages: Analysis of British food purchase data. BMJ Open 2018;8(5):e019788. https://doi.org/10.1136/bmjopen-2017-019788corr1
  46. American Chemical Society. Use of sugars and other carbohydrates in the food industry. A collection of papers comprising the Symposium on the Use of Sugars and Other Carbohydrates in the Food Industry. Presented jointly before the Divisions of Agricultural and Food Chemistry and Carbohydrate Chemistry at the 123rd meeting of the American Chemical Society, Los Angeles, CA, March 1953. 1955. Available at: https://epdf.tips/use-of-sugars-and-other-carbohydrates-in-the-food-industry-advances-in-chemistry.html
  47. Wang J. 56 names for sugar the food industry uses to hide how much is in their products. Health & Wellness. South China Morning Post. 2016. Available at: https://www.scmp.com/lifestyle/health-beauty/article/1937818/56-names-sugar-food-industry-uses-hide-how-much-their
  48. Monteiro CA, Cannon G, Moubarac JC, Levy RB, Louzada MLC, Jaime PC. The UN Decade of Nutrition, the NOVA food classification, and the trouble with ultra-processing. Public Health Nutr 2018;21(1):5–17. https://doi.org/10.1017/S1368980017000234
  49. Ludwig DS. The glycemic index: Physiological mechanisms relating to obesity, diabetes, and cardiovascular disease. JAMA 2002;287:2414–23. https://doi.org/10.1001/jama.287.18.2414
  50. Csete J, Kamarulzaman A, Kazatchkine M, et al. Public health and international drug policy. Lancet 2016;387(10026):1427–80. https://doi.org/10.1016/S0140-6736(16)00619-X
  51. Dictionary.com. Drug. 2019. Available at: http://www.dictionary.com/browse/drug
  52. Cori CF, Cori GT. Carbohydrate metabolism. Ann Rev Biochem 1941;10(1):151–80. https://doi.org/10.1146/annurev.bi.10.070141.001055
  53. Snow HL. Refined sugar: Its use and misuse. The Improvement Era magazine. Lee Foundation for Nutritional Research. The leader in holistic nutrition education. Selene River Press. 1948. Available at: https://www.seleneriverpress.com/historical/refined-sugar-its-use-and-misuse/
  54. DiNicolantonio JJ, Lucan SC. Sugar season. It's everywhere and addictive. The New York Times. 2014. Available at: https://www.nytimes.com/2014/12/23/opinion/sugar-season-its-everywhere-and-addictive.html
  55. Yoshino F, Yoshida A, Umigai N, Kubo K, Lee MC. Crocetin reduces the oxidative stress-induced reactive oxygen species in the stroke-prone spontaneously hypertensive rats (SHRSPs) brain. J Clin Biochem Nutr 2011;49(3):182–7. https://doi.org/10.3164/jcbn.11-01
  56. Tan BL, Norhaizan ME, Liew WPP. Nutrients and oxidative stress: Friend or foe? Oxid Med Cell Longev 2018;2018:9719584. https://doi.org/10.1155/2018/9719584
  57. Bonnefont-Rousselot D. Glucose and reactive oxygen species. Curr Opin Clin Nutr Metab Care 2002;5(5):561–8. https://doi.org/10.1097/00075197-200209000-00016
  58. Prasad K, Dhar I. Oxidative stress as a mechanism of added sugar-induced cardiovascular disease. Int J Angiol 2014;23(4):217–26. https://doi.org/10.1055/s-0034-1387169
  59. Keast RS, Swinburn BA, Sayompark D, Whitelock S, Riddell LJ. Caffeine increases sugar-sweetened beverage consumption in a free-living population: A randomized controlled trial. Br J Nutr 2015;113(2):366–71. https://doi.org/10.1017/S000711451400378X
  60. Evert AB, Dennison M, Gardner CD, et al. Nutrition therapy for adults with diabetes or prediabetes: A consensus report. Diabetes Care 2019;42(5):731–54. https://doi.org/10.2337/dci19-0014
  61. American Heart Associations. How much sugar is too much? Available at: https://www.heart.org/en/healthy-living/healthy-eating/eat-smart/sugar/how-much-sugar-is-too-much
  62. Schulze MB, Manson JE, Ludwig DS, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. JAMA 2004;292(8):927–34. https://doi.org/10.1001/jama.292.8.927
  63. Xu F, Park S, Siegel KR. Factors associated with frequency of sugar-sweetened beverage consumption among US adults with diabetes or prediabetes. Am J Health Promot 2018;32(7):1489–97. https://doi.org/10.1177/0890117117746187
  64. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch Pediatr Adolesc Med 2000;154(6):610–13. https://doi.org/10.1001/archpedi.154.6.610
  65. Whiting SJ, Healey A, Psiuk S, Mirwald R, Kowalski K, Bailey DA. Relationship between carbonated and other low nutrient-dense beverages and bone mineral content of adolescents. Nutr Res 2000;21(8):1107–15. https://doi.org/10.1016/S0271-5317(01)00324-4
  66. Bennett LJ, Totosy de Zepetnek JO, Brett NR, et al. Effect of commercially available sugar-sweetened beverages on subjective appetite and short-term food intake in girls. Nutrients 2018;10(4):pii: E394. https://doi.org/10.3390/nu10040394
  67. Poirier KL, Totosy de Zepetnek JO, Bennett LJ et al., Effect of commercially available sugar-sweetened beverages on subjective appetite and short-term food intake in boys. Nutrients 2019;11(2):pii: E270. https://doi.org/10.3390/nu11020270
  68. Avena NM, Rada P, Thompson HR, Patel A, Madsen KA. Potentially addictive properties of sugar-sweetened beverages among adolescents’ neurochemical effects of intermittent, excessive sugar intake. Neurosci Biobehav Rev 2007;32(1):20–39. https://doi.org/10.1016/j.neubiorev.2007.04.019
  69. Lustig RH. Fructose: Metabolic, hedonic, and societal parallels with ethanol. J Am Diet Assoc 2010;110(9):1307–21. https://doi.org/10.1016/j.jada.2010.06.008
  70. Ahmed SH, Guillem K, Vandaele Y. Sugar addiction: Pushing the drug-sugar analogy to the limit. Curr Opin Clin Nutr Metab Care 2013;16(4):434–9. https://doi.org/10.1097/MCO.0b013e328361c8b8
  71. Lenoir M, Serre F, Cantin L, Ahmed SH. Intense sweetness surpasses cocaine reward. PLoS One 2007;2(8):e698. https://doi.org/10.1371/journal.pone.0000698
  72. American Psychiatric Association. What is addiction? Washington, DC; 2019. Available at: https://www.psychiatry.org/patients-families/addiction/what-is-addiction
  73. O'Brien C. Addiction and dependence in DSMV. Addiction 2010;106(5):866–7. https://doi.org/10.1111/j.1360-0443.2010.03144.x
  74. MacLaren E. Understanding tolerance, dependence, and addiction. An American Addiction Centers Resources; 2019. Available at: https://drugabuse.com/addiction/
  75. National Institute of Drug Abuse. The neurobiology of drug addiction. Advancing Addiction Science; 2019. Available at: https://www.drugabuse.gov/publications/teaching-packets/neurobiology-drug-addiction/section-iii-action-heroin-morphine/8-definition-dependence
  76. De Freitas RL, Kübler JM, Elias-Filho DH, Coimbra NC. Antinociception induced by acute oral administration of sweet substance in young and adult rodents: The role of endogenous opioid peptides chemical mediators and μ (1)-opioid receptors. Pharmacol Biochem Behav 2012;101(2):265–70. https://doi.org/10.1016/j.pbb.2011.12.005
  77. Mysels DJ, Sullivan MA. The relationship between opioid and sugar intake: Review of evidence and clinical applications. J Opioid Manag 2010;6(6):445–52. https://doi.org/10.5055/jom.2010.0043
  78. Kalon E, Hong JY, Tobin C, Schulte T. Psychological and neurobiological correlates of food addiction. Int Rev Neurobiol 2016;129:85–110. https://doi.org/10.1016/bs.irn.2016.06.003
  79. O’Keefe Osborn C. How long does withdrawal from sugar last? Very well mind. 2018. Available at: https://www.verywellmind.com/sugar-withdrawal-symptoms-timeline-and-treatment-4176257
  80. Falbe J, Thompson HR, Patel A, Madsen KA. Potentially addictive properties of sugar-sweetened beverages among adolescents. Appetite 2019;133:130–7. https://doi.org/10.1016/j.appet.2018.10.032
  81. Miller C, Wakefield M, Braunack-Mayer A, et al. Who drinks sugar-sweetened beverages and juice? An Australian population study of behavior, awareness, and attitudes. BMC Obes 2019;6:1. https://doi.org/10.1186/s40608-018-0224-2
  82. Beaglehole R. Sugar-sweetened beverages, obesity, diabetes, and oral health: A preventable crisis. Pac Health Dialog 2014;20(1):39–42.
  83. Bray GA, Popkin BM. Dietary sugar and body weight: Have we reached a crisis in the epidemic of obesity and diabetes? Health be damned! Pour on the sugar. Diabetes Care 2014;37(4):950–6. https://doi.org/10.2337/dc13-2085
  84. Malik VS, Hu FB. Fructose and cardiometabolic health what the evidence from sugar-sweetened beverages tells us. J Am Coll Cardiol 2015;66(14):1615–24.
  85. De Koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation 2012;125(14):1735–41. https://doi.org/10.1161/CIRCULATIONAHA.111.067017
  86. Huang C, Huang J, Tian Y, Yang X, Gu D. Sugar-sweetened beverages consumption and risk of coronary heart disease: A meta-analysis of prospective studies. Atherosclerosis 2014;234(1):11–16. https://doi.org/10.1016/j.atherosclerosis.2014.01.037
  87. Fung TT, Shetty S, Malik SS, Yanchou Njike V. Impact of sugar-sweetened beverages on blood pressure. A consumption and risk of coronary heart disease in women. Am J Clin Nutr 2009;89(4):1037–42. https://doi.org/10.3945/ajcn.2008.27140
  88. Grimes CA, Wright JD, Liu K, Nowson CA, Loria CM. Dietary sodium intake is associated with total fluid and sugar-sweetened beverage consumption in US children and adolescents aged 2–18 y: NHANES 2005–2008. Am J Clin Nutr 2013;98(1):189–96. https://doi.org/10.3945/ajcn.112.051508
  89. Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugar-sweetened beverage consumption, and obesity risk. Pediatrics 2013;131(1):14–21. https://doi.org/10.1542/peds.2012-1628
  90. Malik AH, Akram Y, Shetty S, Malik SS, Yanchou Njike V. Impact of sugar-sweetened beverages on blood pressure. Am J Cardiol 2014;113(9):1574–80. https://doi.org/10.1016/j.amjcard.2014.01.437
  91. Kim YH, Abris GP, Sung MK, Lee JE. Consumption of sugar-sweetened beverages and blood pressure in the United States: The national health and nutrition examination survey 2003–2006. Clin Nutr Res 2012;1(1):85–93. https://doi.org/10.7762/cnr.2012.1.1.85
  92. Dhingra R, Sullivan L, Jacques PF, et al. Soft drink consumption and risk of developing cardiometabolic risk factors and the metabolic syndrome in middle-aged adults in the community. Circulation 2007;116(5):480–8. https://doi.org/10.1161/CIRCULATIONAHA.107.689935
  93. Hert KA, Fisk PS 2nd, Rhee YS, Brunt AR. Decreased consumption of sugar-sweetened beverages improved selected biomarkers of chronic disease risk among US adults: 1999 to 2010. Nutr Res 2014;34(1):58–65. https://doi.org/10.1016/j.nutres.2013.10.005
  94. Malik VS, Li Y, Pan A, et al. Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortality in US adults. Circulation 2019;139(18):2113–25. https://doi.org/10.1161/CIRCULATIONAHA.118.037401
  95. Ruanpeng D, Thongprayoon C, Cheungpasitporn W, Harindhanavudhi T. Sugar, and artificially sweetened beverages linked to obesity: A systematic review and meta-analysis. QJM 2017;110(8):513–20. https://doi.org/10.1093/qjmed/hcx068
  96. Nguyen S, Choi HK, Lustig RH, Thongprayoon C, Cheungpasitporn W, Harindhanavudhi T. Sugar, and blood pressure in adolescents. J Pediatr 2009;154(6):807–13. https://doi.org/10.1016/j.jpeds.2009.01.015
  97. Bernardo WM, Simões RS, Buzzini RF, Nunes VM, Glina F. Adverse effects of the consumption of artificial sweeteners—Systematic review. Rev Assoc Med Bras (1992) 2016;62(2):120–2. https://doi.org/10.1590/1806-9282.62.02.120
  98. Carwile JL, Willett WC, Spiegelman D, et al. Sugar-sweetened beverage consumption and age at menarche in a prospective study of US girls. Hum Reprod 2015;30(3):675–83. https://doi.org/10.1093/humrep/deu349
  99. An R, Maurer G. Consumption of sugar-sweetened beverages and discretionary foods among US adults by purchase location. Eur J Clin Nutr 2016;70(12):1396–400. https://doi.org/10.1038/ejcn.2016.136
  100. Popkin BM, Nielsen SJ. The sweetening of the world's diet. Obes Res 2003;11(11):1325–32. https://doi.org/10.1038/oby.2003.179
  101. Apovian CM. Sugar-sweetened soft drinks, obesity, and type 2 diabetes. JAMA 2004;292(8):978–79. https://doi.org/10.1001/jama.292.8.978
  102. Harpaz D, Yeo LP, Cecchini F, et al. Measuring artificial sweeteners toxicity using a bioluminescent bacterial panel. Molecules 2018;23(10):2454. https://doi.org/10.3390/molecules23102454
  103. Chiu YH, Afeiche MC, Gaskins AJ, et al. Sugar-sweetened beverage intake in relation to semen quality and reproductive hormone levels in young men. Hum Reprod 2014;29(7):1575–84. https://doi.org/10.1093/humrep/deu102
  104. Chen L, Xie YM, Pei JH, et al. Sugar-sweetened beverage intake and serum testosterone levels in adult males 20–39 years old in the United States. Reprod Biol Endocrinol 2018;16(1):61. https://doi.org/10.1186/s12958-018-0378-2
  105. Hatch EE, Wesselink AK, Hahn KA, et al. Intake of sugar-sweetened beverages and fecundability in a North American preconception cohort. Epidemiology 2018;29(3):369–78. https://doi.org/10.1097/EDE.0000000000000812
  106. Katib A. Mechanisms linking obesity to male infertility. Cent European J Urol 2015;68(1):79–85. https://doi.org/10.5173/ceju.2015.01.435
  107. Vartanian L, Schwartz M, Brownell K. Effects of soft drink consumption on nutrition and health: A systematic review and meta-analysis. Am J Public Health 2007;97(4):667–75. https://doi.org/10.2105/AJPH.2005.083782
  108. Pan A, Hu FB. Effects of carbohydrates on satiety: Differences between liquid and solid food. Curr Opin Clin Nutr Metab Care 2011;14:385–90. https://doi.org/10.1097/MCO.0b013e328346df36
  109. Mullie P, Deliens T, Clarys P. Relation between sugar-sweetened beverage consumption, nutrition, and lifestyle in a military population. Mil Med 2016;181(10):1335–9. https://doi.org/10.7205/MILMED-D-15-00453
  110. Rajeshwari R, Yang SJ, Nicklas TA, Berenson GS. Secular trends in children sweetened-beverage consumption (1973 to 1994): The Bogalusa Heart Study. J Am Diet Assoc 2005;105:208–14. https://doi.org/10.1016/j.jada.2004.11.026
  111. Harnack L, Stang J, Story M. Soft drink consumption among US children and adolescents: Nutritional consequences. J Am Diet Assoc 1999;99:436–41. https://doi.org/10.1016/S0002-8223(99)00106-6
  112. Newby PK, Peterson KE, Berkey CS, Leppert J, Willett WC, Colditz GA. Beverage consumption is not associated with changes in weight and body mass index among low-income preschool children in North Dakota. J Am Diet Assoc 2004;104:1086–94. https://doi.org/10.1016/j.jada.2004.04.020
  113. Rodriguez-Artalejo F, Garcia EL, Gorgojo L, et al. Consumption of bakery products, sweetened soft drinks, and yogurt among children aged 6–7 years: Association with nutrient intake and overall diet quality. Br J Nutr 2003;89:419–29. https://doi.org/10.1016/j.jada.2004.04.020
  114. Guenther PM. Beverages in the diets of American teenagers. J Am Diet Assoc 1986;86:493–9.
  115. Bowman SA. Beverage choices of young females: Changes and impact on nutrient intakes. J Am Diet Assoc 2002;102:1234–9. https://doi.org/10.1016/S0002-8223(02)90273-7
  116. McGartland C, Robson PJ, Murray L, et al. Carbonated soft drink consumption and bone mineral density in adolescence: The Northern Ireland Young Hearts project. J Bone Miner Res 2003;18:1563–9. https://doi.org/10.1359/jbmr.2003.18.9.1563
  117. Bes-Rastrollo M, Sanchez-Villegas A, Gomez-Gracia E, Martinez JA, Pajares RM, Martinez-Gonzalez MA. Predictors of weight gain in a Mediterranean cohort: The Seguimiento Universidad de Navarra Study 1. Am J Clin Nutr 2006;83:362–70. https://doi.org/10.1093/ajcn/83.2.362
  118. Storey ML, Forshee RA, Anderson PA. Associations of adequate intake of calcium with diet, beverage consumption, and demographic characteristics among children and adolescents. J Am Coll Nutr 2004;23:18–33. https://doi.org/10.1080/07315724.2004.10719339
  119. Frary CD, Johnson RK, Wang MQ. Children and adolescents’ choices of foods and beverages high in added sugars are associated with intakes of key nutrients and food groups. J Adolesc Health 2004;34:56–63. https://doi.org/10.1016/S1054-139X(03)00248-9
  120. Ballew C, Kuester S, Gillespie C. Beverage choices affect adequacy of children’s nutrient intakes. Arch Pediatr Adolesc Med 2000;154:1148–52. https://doi.org/10.1001/archpedi.154.11.1148
  121. Skinner JD, Carruth BR, Moran J III, Houck K, Coletta F. Fruit juice intake is not related to children’s growth. Pediatrics 1999;103:58–64. https://doi.org/10.1542/peds.103.1.58
  122. Fisher JO, Mitchell DC, Smiciklas-Wright H, Birch LL. Maternal milk consumption predicts the tradeoff between milk and soft drinks in young girls’ diets. J Nutr 2000;131:246–50. https://doi.org/10.1093/jn/131.2.246
  123. Kim SH, Morton DJ, Barrett-Connor EL. Carbonated beverage consumption and bone mineral density among older women: The Rancho Bernardo Study. Am J Public Health 1997;87:276–9. https://doi.org/10.2105/AJPH.87.2.276
  124. Ma D, Jones G. Soft drink and milk consumption, physical activity, bone mass, and upper limb fractures in children: A population-based case-control study. Calcif Tissue Int 2004;75(4):286–91. https://doi.org/10.1007/s00223-004-0274-y
  125. Barr SI. Associations of social and demographic variables with calcium intakes of high school students. J Am Diet Assoc 1994;94(3):260–6, 269. https://doi.org/10.1016/0002-8223(94)90366-2
  126. Guthrie JF. Dietary patterns and personal characteristics of women consuming recommended amounts of calcium. Fam Econ Nutr Rev 1996;9(3):33–49.
  127. Skinner JD, Bounds W, Carruth BR, Ziegler P. Longitudinal calcium intake is negatively related to children’s body fat indexes. J Am Diet Assoc 2003;103(12):1626–31. https://doi.org/10.1016/j.jada.2003.09.018
  128. Hu FB. Resolved: There is sufficient scientific evidence that decreasing sugar-sweetened beverage consumption will reduce the prevalence of obesity and obesity-related diseases. Obes Rev 2013;14(8):606–19. https://doi.org/10.1111/obr.12040
  129. Rippe JM, Angelopoulos TJ. Relationship between added sugars consumption and chronic disease risk factors: Current understanding. Nutrients 2016;8(11):697. https://doi.org/10.3390/nu8110697
  130. Davy BM, Harrell K, Stewart J, King DS. Bodyweight status, dietary habits, and physical activity levels of middle school-aged children in rural Mississippi. South Med J 2004;97:571–7. https://doi.org/10.1097/00007611-200406000-00012
  131. De Castro JM. The effects of the spontaneous ingestion of particular foods or beverages on the meal pattern and overall nutrient intake of humans. Physiol Behav 1993;53:1133–44. https://doi.org/10.1016/0031-9384(93)90370-U
  132. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: Effects on food intake and body weight. Int J Obes Relat Metab Disord 2000;24:794–800. https://doi.org/10.1038/sj.ijo.0801229
  133. Raben A, Vasilaras TH, Moller AC, Astrup A. Sucrose compared with artificial sweeteners: Different effects on ad libitum food intake and body weight after 10 weeks of supplementation in overweight subjects. Am J Clin Nutr 2002;76:721–9. https://doi.org/10.1093/ajcn/76.4.721
  134. Almiron-Roig E, Drewnowski A. Hunger, thirst, and energy intakes following consumption of caloric beverages. Physiol Behav 2003;79:767–73. https://doi.org/10.1016/S0031-9384(03)00212-9
  135. Melanson KJ, Westerterp-Plantenga MS, Campfield LA, Saris WH. Blood glucose and meal patterns in time-blinded males, after aspartame, carbohydrate, and fat consumption, in relation to sweetness perception. Br J Nutr 1999;82:437–46. https://doi.org/10.1017/S0007114599001695
  136. Lavin JH, French SJ, Read NW. The effect of sucrose- and aspartame-sweetened drinks on energy intake, hunger, and food choice of female, moderately restrained eaters. Int J Obes Relat Metab Disord 1997;21:37–42. https://doi.org/10.1038/sj.ijo.0800360
  137. Deshpande G, Mapanga RF, Essop MF. Frequent sugar-sweetened beverage consumption and the onset of cardiometabolic diseases: Cause for concern? J Endocr Soc 2017;1(11):1372–85. https://doi.org/10.1210/js.2017-00262
  138. Mirmiran P, Yuzbashian E, Asghari G, Hosseinpour-Niazi S, Azizi F. Consumption of sugar-sweetened beverage is associated with incidence of metabolic syndrome in Tehranian children and adolescents. Nutr Metab (Lond). 2015;12:25. https://doi.org/10.1186/s12986-015-0021-6
  139. DiNicolantonio JJ, Berger A. Added sugars drive nutrient and energy deficit in obesity: A new paradigm. Open Heart 2016;3(2):e000469. https://doi.org/10.1136/openhrt-2016-000469
  140. Shimony MK, Schliep KC, Schisterman EF, et al. The relationship between sugar-sweetened beverages and liver enzymes among healthy premenopausal women: A prospective cohort study. Eur J Nutr 2016;55(2):569–76. https://doi.org/10.1007/s00394-015-0876-3
  141. Smith A. An inquiry into the nature and causes of the wealth of nations. London: W. Strahan and T. Cadell; 1776.
  142. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: Systematic review and metaanalyses of randomized controlled trials and cohort studies. BMJ 2012;346:e7492. https://doi.org/10.1136/bmj.e7492
  143. Nawrot P, Jordan S, Eastwood J, Rotstein J, Hugenholtz A, Feeley M. Effects of caffeine on human health. Food Addit Contam 2003;20(1):1–30. https://doi.org/10.1080/0265203021000007840
  144. Prather AA, Leung CW, Adler NE, Ritchie L, Laraia B, Epel ES. Short and sweet: Associations between self-reported sleep duration and sugar-sweetened beverage consumption among adults in the United States. Sleep Health 2016;2(4):272–6. https://doi.org/10.1016/j.sleh.2016.09.007
  145. Petersen PE. WHO Oral Health Program. The world oral health report 2003: Continuous improvement of oral health in the 21st century—The approach of the WHO Global Oral Health Programme/Poul Erik Petersen. World Health Organization; 2003. Available at: https://apps.who.int/iris/bitstream/handle/10665/68506/WHO_NMH_NPH_ORH_03.2.pdf?sequence=1&isAllowed=y
  146. Williams DM. The research agenda on oral health inequalities: The IADR-GOHIRA initiative. Med Princ Pract 2014;23(Suppl 1):52–9. https://doi.org/10.1159/000356934
  147. Williams DM. Global oral health inequalities: The research agenda. Adv Dent Res 2011;23(2):198–200. https://doi.org/10.1177/0022034511402014
  148. Petersen PE. Global policy for improvement of oral health in the 21st century—Implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dent Oral Epidemiol 2009;37(1):1–8. https://doi.org/10.1111/j.1600-0528.2008.00448.x
  149. Pitts N, Amaechi B, Niederman R, Acevedo AM, Vianna R, Ganss C, et al. Global oral health inequalities: Dental caries task group—Research agenda. Adv Dent Res 2011;23(2):211–20. https://doi.org/10.1177/0022034511402016
  150. National Institute of Dental and Craniofacial Research. National Institute of Dental and Craniofacial Research 2000. Oral health in America: A report of the Surgeon General. 2000. Available at: http://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/sgr/
  151. Petersen PE. World Health Organization global policy for improvement of oral health—World Health Assembly 2007. Int Dent J 2008;58(3):115–21. https://doi.org/10.1111/j.1875-595X.2008.tb00185.x
  152. Petersen PE, Yamamoto T. Improving the oral health of older people: The approach of the WHO Global Oral Health Programme. Community Dent Oral Epidemiol 2005;33(2):81–92. https://doi.org/10.1111/j.1600-0528.2004.00219.x
  153. Matear DW. Demonstrating the need for oral health education in geriatric institutions. Probe 1999;33(2):66–71.
  154. Sanford A. The tragedy of “Mountain Dew mouth” and the U.S.’s insane approach to dental care. Lack of dental care is causing a mouthful of trouble—And it will get worse. 2017. Available at: https://www.salon.com/2017/06/20/the-tragedy-of-mountain-dew-mouth-and-the-u-s-s-insane-approach-to-dental-care_partner/
  155. Song IS, Han K, Ko Y, Park YG, Ryu JJ, Park JB. Associations between the consumption of carbonated beverages and periodontal disease. The 2008–2010 Korea national health and nutrition examination survey. Medicine (Baltimore). 2016;95(28):e4253. https://doi.org/10.1097/MD.0000000000004253
  156. Lll KG, Klimczak A, Rachubiński P, Jagłowska A, Kwapiszewska A. Consumption of sweetened beverages as a risk factor of colonization of oral cavity by fungi—Eating habits of university student. Ann Parasitol 2015;61(3):175–82. https://doi.org/10.17420/ap6103.04
  157. Vikingur L. Effects of sugar-sweetened beverages on oral health. 2015. Available at: https://lifecaredental.com.au/dental-advice/effects-of-sugar-sweetened-beverages-on-oral-health
  158. Diabetes Queensland. Diet and new generation soft drinks linked with poor oral health. Brisbane; 2017. Available at: https://www.diabetesqld.org.au/media-centre/2017/november/oral-health-impact-of-sugar-sweetened-beverages-overlooked.aspx
  159. Hardy LL, Bell J, Bauman A, Mihrshahi S. Association between adolescents’ consumption of total and different types of sugar-sweetened beverages with oral health impacts and weight status. Aust N Z J Public Health 2018;42(1):22–6. https://doi.org/10.1111/1753-6405.12749
  160. Jain P, Nihill P, Sobkowski J, Agustin MZ. Commercial soft drinks: pH and in vitro dissolution of enamel. Gen Dent 2007;55(2):150–5.
  161. Idris AM, Vani NV, Almutari DA, Jafar MA, Boreak N. Analysis of sugars and pH in commercially available soft drinks in Saudi Arabia with a brief review on their dental implications. J Int Soc Prev Community Dent 2016;6(Suppl 3):S192–6. https://doi.org/10.4103/2231-0762.197190
  162. Reddy A, Norris DF, Momeni SS, Waldo B, Ruby JD. The pH of beverages in the United States. J Am Dent Assoc 2016;147(4):255–63. https://doi.org/10.1016/j.adaj.2015.10.019
  163. Mishra MB, Mishra S. Sugar-sweetened beverages: General and oral health hazards in children and adolescents. Int J Clin Ped Dent 2011;4(2):119–23. https://doi.org/10.5005/jp-journals-10005-1094
  164. Hans R, Thomas S, Garla B, Dagli RJ, Hans MK. Effect of various sugary beverages on salivary pH, flow rate, and oral clearance rate amongst adults. Scientifica (Cairo) 2016;2016:5027283. https://doi.org/10.1155/2016/5027283
  165. Zero DT. Sugars—The arch-criminal? Caries Res 2004;38(3):277–85. https://doi.org/10.1159/000077767
  166. Gupta P, Gupta N, Pawar AP, Birajdar SS, Natt AS, Singh HP. Role of sugar and sugar substitutes in dental caries: A review. ISRN Dent 2013;2013:519421. https://doi.org/10.1155/2013/519421
  167. Chen F, Wang D. Novel technologies for the prevention and treatment of dental caries: A patent survey. Expert Opin Ther Pat 2010;20(5):681–94. https://doi.org/10.1517/13543771003720491
  168. Georgios A, Vassiliki T, Sotirios K. Acidogenicity and acidurance of dental plaque and saliva sediment from adults in relation to caries activity and chlorhexidine exposure. J Oral Microbiol 2015;7:26197. https://doi.org/10.3402/jom.v7.26197
  169. Forssten SD, Björklund M, Ouwehand AC. Streptococcus mutans, caries, and simulation models. Nutrients 2010;2(3):290–8. https://doi.org/10.3390/nu2030290
  170. Lemos JA, Quivey RG Jr, Koo H, Abranches J. Streptococcus mutans: A new Gram-positive paradigm? Microbiology 2013;159(Pt 3):436–45. https://doi.org/10.1099/mic.0.066134-0
  171. Tehrani MH, Asghari G, Hajiahmadi M. Comparing Streptococcus mutans and Lactobacillus colony count changes following green tea mouth rinse or sodium fluoride mouth rinse use in children (Randomized, double-blind controlled clinical trial). Dent Res J (Isfahan) 2011;8(Suppl 1):S58–63.
  172. Ahmed A, Dachang W, Lei Z, Jianjun L, Juanjuan Q, Yi X. Effect of Lactobacillus species on Streptococcus mutans biofilm formation. Pak J Pharm Sci 2014;27(5 Spec No):1523–8.
  173. Beighton D, Hellyer PH, Lynch EJ, Heath MR. Salivary levels of mutans streptococci, lactobacilli, yeasts, and root caries prevalence in non-institutionalized elderly dental patients. Community Dent Oral Epidemiol 1991;19:302–7. https://doi.org/10.1111/j.1600-0528.1991.tb00172.x
  174. Drewnowski A, Rehm CD. Consumption of added sugars among us children and adults by food purchase location and food source. Am J Clin Nutr 2014;100:901–7. https://doi.org/10.3945/ajcn.114.089458
  175. U.S. Department of Health and Human Services and U.S. Department of Agriculture. Dietary guidelines for Americans 2015–2020. Eight Edition. New York: Skyhorse Publishing Inc.; 2015.
  176. Ervin R, Kit B, Carroll M, Ogden C. Consumption of added sugar among U.S. children and adolescents, 2005–2008. NCHS Data Brief 2012;87:1–8.
  177. Ervin RB, Ogden CL. Consumption of added sugars among U.S. adults, 2005–2010. NCHS Data Brief 2013;122:1–8.
  178. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among U.S. Adults, 2011–2014. NCHS Data Brief 2017;270:1–8.
  179. Gishti O, Gaillard R, Durmus B, et al. BMI, total and abdominal fat distribution, and cardiovascular risk factors in school-age children. Pediatr Res 2015;77:710–18. https://doi.org/10.1038/pr.2015.29
  180. Kumar S, Kelly AS. Review of childhood obesity: From epidemiology, etiology, and comorbidities to clinical assessment and treatment. Mayo Clin Proc 2017;92:251–65. https://doi.org/10.1016/j.mayocp.2016.09.017
  181. Zuba A, Warschburger P. The role of weight teasing and weight bias internalization in psychological functioning: A prospective study among school-aged children. Eur. Child Adolesc Psychiatry 2017;26:1245–55. https://doi.org/10.1007/s00787-017-0982-2
  182. Armfield JM, Spencer AJ, Roberts-Thomson KF, Plastow K. Water fluoridation and the association of sugar-sweetened beverage consumption and dental caries in Australian children. Am J Public Health 2013;103:494–500. https://doi.org/10.2105/AJPH.2012.300889
  183. Wilder J, Kaste L, Handler A, Chapple-McGruder T, Rankin K. The association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Public Health Dent 2016;76:76–84. https://doi.org/10.1111/jphd.12116
  184. Keller K, Kirzner J, Pietrobelli A, St-Onge M, Faith M. Increased sweetened beverage intake is associated with reduced milk and calcium intake in 3- to 7-year-old children at multi-item laboratory lunches. J Am Diet Assoc 2009;109:497–501. https://doi.org/10.1016/j.jada.2008.11.030
  185. Leung C, DiMatteo S, Gosliner W, Ritchie L. Sugar-sweetened beverage and water intake in relation to diet quality in U.S. Children. Am J Prev Med 2018;54:394–402. https://doi.org/10.1016/j.amepre.2017.11.005
  186. Keast D, Fulgoni V, Nicklas T, O’Neil C. Food sources of energy and nutrients among children in the United States: National health and nutrition examination survey 2003–2006. Nutrients 2013;5:283–301. https://doi.org/10.3390/nu5010283
  187. American Academy of Pediatric Dentistry. Policy on dietary recommendations for infants, children, and adolescents. Policy Man 2012;37:2015–2016.
  188. Handel M, Heitmann B, Abrahamsen B. Nutrient, and food intakes in early life and risk of childhood fractures: A systematic review and meta-analysis. Am J Clin Nutr 2015;102:1182–95. https://doi.org/10.3945/ajcn.115.108456
  189. Eck KM, Dinesen A, Garcia E, et al. “Your Body Feels Better When You Drink Water”: Parent and school-age children's sugar-sweetened beverage cognitions. Nutrients 2018;10(9):pii: E1232. https://doi.org/10.3390/nu10091232
  190. Wilder JR, Kaste LM, Handler A, Chapple-McGruder T, Rankin K. The association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Public Health Dent 2016;76(1):76–84. https://doi.org/10.1111/jphd.12116
  191. Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, Suominen AL. Sugar-sweetened beverages and dental caries in adults: A 4-year prospective study. J Dent 2014;42(8):952–8. https://doi.org/10.1016/j.jdent.2014.04.011
  192. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988–1994, and 1999–2004. Vital Health Stat 2007;248:1–92.
  193. Lewis C, Stout J. Toothache in U.S. children. Arch Pediatr Adolesc Med 2010;164:1059–63. https://doi.org/10.1001/archpediatrics.2010.206
  194. Vargas CM, Monajemy N, Khurana P, Tinanoff N. Oral health status of preschool children attending Head Start in Maryland, 2000. Pediatr Dent 2002;24:257–63.
  195. Mayo Clinic Staff. Oral health: A window to your overall health. Healthy Lifestyle, Adult health; 2018. Available at: https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/dental/art-20047475
  196. Davis CP. Chapter 6: Normal flora. In: Baron S, editor. Medical microbiology. 4th ed. Galveston, TX: University of Texas Medical Branch at Galveston; 1996. Available at: https://www.ncbi.nlm.nih.gov/books/NBK7617/
  197. Avila M, Ojcius DM, Yilmaz O. The oral microbiota: Living with a permanent guest. DNA Cell Biol 2009;28(8):405–11. https://doi.org/10.1089/dna.2009.0874
  198. Gao L, Xu T, Huang G, Jiang S, Gu Y, Chen F. Oral microbiomes: More and more importance in oral cavity and whole body. Protein Cell 2018;9(5):488–500. https://doi.org/10.1007/s13238-018-0548-1
  199. Zhang Y, Wang X, Li H, Ni C, Du Z, Yan F. Human oral microbiota and its modulation for oral health. Biomed Pharmacother 2018;99:883–93. https://doi.org/10.1016/j.biopha.2018.01.146
  200. Dewhirst FE, Chen T, Izard J, et al. The human oral microbiome. J Bacteriol 2010;192(19):5002–17. https://doi.org/10.1128/JB.00542-10
  201. Carlsson J, Johansson T. Sugar, and the production of bacteria in the human mouth. Caries Res 1973;7(4):273–82. https://doi.org/10.1159/000259851
  202. Rouabhia M. Interactions between host and oral commensal microorganisms are key events in health and disease status. Can J Infect Dis 2002;13(1):47–51. https://doi.org/10.1155/2002/580476
  203. Lederberg J. “Ome sweet” omics—A genealogical treasury of words. The Scientist. 2001. Available at: https://www.the-scientist.com/commentary/ome-sweet-omics---a-genealogical-treasury-of-words-54889
  204. Haque SZ, Haque M. The ecological community of commensal, symbiotic, and pathogenic gastrointestinal microorganisms—An appraisal. Clin Exp Gastroenterol 2017;10:91–103. https://doi.org/10.2147/CEG.S126243
  205. Liang D, Leung RK, Guan W, Au WW. Involvement of gut microbiome in human health and disease: Brief overview, knowledge gaps, and research opportunities. Gut Pathog 2018;10:3. https://doi.org/10.1186/s13099-018-0230-4
  206. Wang B, Yao M, Lv L, Ling Z, Li L. The human microbiota in health and disease. Engineering 2017;3(1):71–82. https://doi.org/10.1016/J.ENG.2017.01.008
  207. Belkaid Y, Hand TW. Role of the microbiota in immunity and inflammation. Cell 2014;157(1):121–41. https://doi.org/10.1016/j.cell.2014.03.011
  208. Arnolds KL, Lozupone CA. Striking a balance with help from our little friends—How the gut microbiota contributes to immune homeostasis. Yale J Biol Med 2016;89(3):389–95.
  209. Hand TW. The role of the microbiota in shaping infectious immunity. Trends Immunol 2016;37(10):647–58. https://doi.org/10.1016/j.it.2016.08.007
  210. Ubeda C, Djukovic A, Isaac S. Roles of the intestinal microbiota in pathogen protection. Clin Transl Immunology 2017;6(2):e128. https://doi.org/10.1038/cti.2017.2
  211. Keller MK, Kressirer CA, Belstrøm D, Twetman S, Tanner ACR. Oral microbial profiles of individuals with different levels of sugar intake. J Oral Microbiol 2017;9(1):1355207. https://doi.org/10.1080/20002297.2017.1355207
  212. Expanded Human Oral Microbiome Database (eHOMD). 2018. Available at: http://www.homd.org/
  213. Morhart RE, Fitzgerald RJ. Nutritional determinants of the ecology of the oral flora. Dent Clin North Am 1976;20(3):473–89.
  214. Touger-Decker R, van Loveren C. Sugars and dental caries. Am J Clin Nutr 2003;78(4):881S–92S. https://doi.org/10.1093/ajcn/78.4.881S
  215. Slavin J, Carlson J. Carbohydrates. Adv Nutr 2014;5(6):760–1. https://doi.org/10.3945/an.114.006163
  216. Wade WG. The oral microbiome in health and disease. Pharmacol Res 2013;69(1):137–43. https://doi.org/10.1016/j.phrs.2012.11.006
  217. Hojo K, Nagaoka S, Ohshima T, Maeda N. Bacterial interactions in dental biofilm development. J Dent Res 2009;88(11):982–90. https://doi.org/10.1177/0022034509346811
  218. Aas JA, Griffen AL, Dardis SR, et al. Bacteria of dental caries in primary and permanent teeth in children and young adults. J Clin Microbiol 2008;46(4):1407–17. https://doi.org/10.1128/JCM.01410-07
  219. Takahashi N, Nyvad B. The role of bacteria in the caries process: Ecological perspectives. J Dent Res 2011;90(3):294–303. https://doi.org/10.1177/0022034510379602
  220. Banas JA, Drake DR. Are the mutans streptococci still considered relevant to understanding the microbial etiology of dental caries? BMC Oral Health 2018;18(1):129. https://doi.org/10.1186/s12903-018-0595-2
  221. Hughes CV, Dahlan M, Papadopolou E, et al. Aciduric microbiota and mutans streptococci in severe and recurrent severe early childhood caries. Pediatr Dent 2012;34(2):e16–23.
  222. Tanzer JM, Livingston J, Thompson AM. The microbiology of primary dental caries in humans. J Dent Educ 2001;65:102837.
  223. Welsh JA, Lundeen EA, Stein AD. The sugar-sweetened beverage wars: Public health and the role of the beverage industry. Curr Opin Endocrinol Diabetes Obes 2013;20(5):401–6. https://doi.org/10.1097/01.med.0000432610.96107.f5
  224. Sanghavi A, Siddiqui NJ. Advancing oral health policy and advocacy to prevent childhood obesity and reduce children's consumption of sugar-sweetened beverages. J Public Health Dent 2017;77(Suppl 1):S88–95. https://doi.org/10.1111/jphd.12235
  225. Tamir O, Cohen-Yogev T, Furman-Assaf S, Endevelt R. Taxation of sugar-sweetened beverages and unhealthy foods: A qualitative study of key opinion leaders' views. Isr J Health Policy Res 2018;7(1):43. https://doi.org/10.1186/s13584-018-0240-1
  226. Maniadakis N, Kapaki V, Damianidi L, Kourlaba G. A systematic review of the effectiveness of taxes on nonalcoholic beverages and high-in-fat foods as a means to prevent obesity trends. Clinicoecon Outcomes Res 2013;5:519–43. https://doi.org/10.2147/CEOR.S49659
  227. Waterlander WE, Ni Mhurchu C, Steenhuis IH. Effects of a price increase on purchases of sugar-sweetened beverages. Results from a randomized controlled trial. Appetite 2014;78:32–9. https://doi.org/10.1016/j.appet.2014.03.012
  228. Bascuñán J, Cuadrado C. Effectiveness of sugar-sweetened beverages taxes to reduce obesity: Evidence brief for policy. Medwave 2017;17(8):e7054. https://doi.org/10.5867/medwave.2017.08.7054
  229. Wright A, Smith KE, Hellowell M. Policy lessons from health taxes: A systematic review of empirical studies. BMC Public Health 2017;17(1):583. https://doi.org/10.1186/s12889-017-4497-z
  230. International Development Research Center. Evaluation of South Africa’s excise tax on sugar-sweetened beverages. Available at: https://www.idrc.ca/en/project/evaluation-south-africas-excise-tax-sugar-sweetened-beverages
  231. Redondo M, Hernández-Aguado I, Lumbreras B. The impact of the tax on sweetened beverages: A systematic review. Am J Clin Nutr 2018;108(3):548–63. https://doi.org/10.1093/ajcn/nqy135
  232. Backholer K, Sarink D, Beauchamp A, et al. The impact of a tax on sugar-sweetened beverages according to socioeconomic position: A systematic review of the evidence. Public Health Nutr 2016;19(17):3070–84. https://doi.org/10.1017/S136898001600104X
  233. Silver LD, Ng SW, Ryan-Ibarra S, et al. Changes in prices, sales, consumer spending, and beverage consumption one year after a tax on sugar-sweetened beverages in Berkeley, California, US: A before-and-after study. PLoS Med 2017;14(4):e1002283. https://doi.org/10.1371/journal.pmed.1002283
  234. Lee MM, Falbe J, Schillinger D, Basu S, McCulloch CE, Madsen KA. Sugar-sweetened beverage consumption 3 years after the Berkeley, California, Sugar-Sweetened Beverage Tax. Am J Public Health 2019;109(4):637–9. https://doi.org/10.2105/AJPH.2019.304971
  235. Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar-sweetened beverages: Observational study. BMJ 2016;352:h6704. https://doi.org/10.1136/bmj.h6704
  236. Colchero MA, Rivera-Dommarco J, Popkin BM, Ng SW. In Mexico, evidence of sustained consumer response two years after implementing a sugar-sweetened beverage tax. Health Aff (Millwood) 2017;36(3):564–71. https://doi.org/10.1377/hlthaff.2016.1231
  237. Lloyd-Williams F, Bromley H, Orton L, et al. Smorgasbord or symphony? Assessing public health nutrition policies across 30 European countries using a novel framework. BMC Public Health 2014;14:1195. https://doi.org/10.1186/1471-2458-14-1195
  238. Thow AM, Downs SM, Mayes C, Trevena H, Waqanivalu T, Cawley J. Fiscal policy to improve diets and prevent noncommunicable diseases: From recommendations to action. Bull World Health Organ 2018;96(3):201–10. https://doi.org/10.2471/BLT.17.195982
  239. Thow AM, Quested C, Juventin L, Kun R, Khan AN, Swinburn B. Taxing soft drinks in the Pacific: Implementation lessons for improving health. Health Promot Int 2011;26(1):55–64. https://doi.org/10.1093/heapro/daq057
  240. Arthur R. South Africa introduces sugar tax. Beverage Daily.Com, William Reed Business Media Ltd.; 2018. Available at: https://www.beveragedaily.com/Article/2018/04/03/South-Africa-introduces-sugar-tax
  241. World Health Organization. WHO supports proposed sugar-sweetened beverages tax in South Africa. WHO; 2017. Available at: https://www.afro.who.int/news/who-supports-proposed-sugar-sweetened-beverages-tax-south-africa
  242. The Government of the UK. Soft Drinks Industry Levy comes into effect. 2018. Available at: https://www.gov.uk/government/news/soft-drinks-industry-levy-comes-into-effect
  243. World Health Organization. Monitoring food and beverage marketing to children via television and the Internet. A proposed tool for the WHO European Region. Copenhagen: WHO Regional Office for Europe; 2016. Available at: http://www.euro.who.int/data/assets/pdf_file/0011/333956/food-children-TV-internet-en.pdf?ua=1
  244. Hawkes C, Smith TG, Jewell J, et al. Smart food policies for obesity prevention. Lancet 2015;385(9985):2410–21. https://doi.org/10.1016/S0140-6736(14)61745-1