Sugar Sweetened Beverages & Total Energy Intake: Studies Suggest That Normal-, Overweight & Obese Women CAN Compensate for 168 Additional Sugar Calories Per Day

Usually they are touted as the reason for weight gain: Sugar-containing soft drinks like the Scottish brew Irn Bru. In the study at hand, however, they helped 41 obese women lose weight - how come?

Despite the fact that it is not the first of it's kind, I decided that the paper Roy Nelson sent me the a couple of days ago may still be worth being covered in a brief article. Marie Reid and her colleagues were after all able to show that we can, theoretically and without conscious effort, compensate for the additional energy intake from sugar-sweetened beverages.

As I already mentioned, this is not the first study Reid and her colleagues from the Hull, Ulster and Herriot-Watt Universities in the UK conducted, but it is the first one where the subjects, obese women, with previous diet experience, came right from the subgroup of the population of whom we simply assume that their weight problems would (partly) result from these "empty calories".

Would the women "recognize" the 168kcal of pure sugar in their diets?

After exclusion and dropouts, Marie Reid et al. were left with a total of 41 healthy obese (BMI 30– 35 kg/m²) 20-50 year-old women who were randomly assigned to consume sucrose (n=20) or aspartame (n=21) drinks over 4 weeks in a parallel single-blind design.

Based on the previously mentioned experiments with normal- and overweight women, the researchers knew women with higher body weights had a harder time to compensate for the 168kcal the sugar-sweetened drinks delivered than their lean peers. It was thus interesting to see, whether the obese women (1) would compensate for the additional energy intake and (2) whether the compensation would be less pronounced than in the lean and overweight participants of the previous studies.

What's missing from the study at hand are the really important things, i.e. the changes in blood glucose and lipid metabolism and the differences in waist circumference and / or body fat levels. So whatever the scale of the subjects said, this and the previous studies by Reid et al. don't provide the basis for an acquittal of sugar sweetened beverages (learn more about the debate the role of Pepsi, Coke & Co in the diabesity epidemic).

Instead of simply having their subjects fill dietary records, the scientists used the weight response to judge, whether or not the women fully or partly compensated for the additional energy intake from the sugar sweetened beverages (note: the beverages contained regular sugar, no HFCS). Reid et al. did yet also analyze the changes in macronutrient composition to elucidate, whether the expected reduction in regular (food) energy intake would go at the expense of any particular macronutrient, i.e. carbs, proteins or fats.

Figure 1: Macronutrient and energy intake of the sugar (left) and aspartame (right) group (Reid. 2013)

The test drinks the scientists used came in 250 ml bottles. The women were instructed to consume four of these bottler, the content of which was sweetened with plain sucrose (fructose + glucose) or aspartame. Of the latter, the commercially available soft drinks (Irn Bru) contained

• 10.5g of sucrose, but no aspartame in the regular and (sugar)
• 0g of sucrose and a miniscule amount of aspartame in the diet variety (aspartame)

If you  do the math you can easily calculate that the regular Irn Bru provided an additional energy intake of 4x10.5g/day x 4kcal/g = 168kcal/day and a total of 4704kcal if we take the whole 4-week study period. According to the faulty rule of thumb that informs us that 1lbs of fat would equal 3,500kcal (learn why this is *bs*), the women in the "regular" Irn Bru group (sugar) should end up with "exactly" (*rofl*) 672g of additional fat on their hips.

Sugar doesn't make you fat and artificial sweeteners seem to hamper weight loss!?

I guess (or hope) that you will not really have expected to see those 672 extra grams of fat on the hips of Reid's, subjects at the end of the study. Still, most of you will probably have expected that the ladies did gain weight, right? Much to my own surprise, this was not the case: In fact, the vast majority of the ladies missed the predicted weight gain by more than 1kg (1.72 (SD 0.47) kg).

Figure 2: Illustration of the results of the study at hand (obese women) and previous studies with normal- and overweight women all of which showed sufficient energy compensation for the 4x250ml soft drinks  (Reid. 2007, 2010, 2013); note the listed "weight loss", e.g. -1.72kg, denotes the difference between the actual and the predicted body weight, see red box!

Now, being part of a study like this certainly is a confounding factor that could precipitate to conscious energy restriction. If this was the reason the ladies didn't gain weight, though, the women in the aspartame group would actually have had to lose a significant amount of weight.

It's not like the lean or overweight  women did not gain any weight at all.

This is not "sugar induced weight loss"! If you look at the graphs from the previous studies (left) in which Reid et al. did not use the "compared to expected weight gain" trick, it's obvious that only the lean women got away without weight gain.  In the overweight and obese women, there was a small, but due to the large outliers statistically non-significant increase in body weight.

I mean, you would certainly expect the women in the placebo group to take the same measure to make sure the potentially sugary (remember this is a randomized, blinded study) brew they were drinking would not end up on their hips.

A brief glance at the total energy intake in Figure 1 appears to confirm that: The women in the aspartame group did also reduce their energy intake. Due to significant differences among the study participants this did however not lead to a net change in body weight. From a statistical perspective, this means that the body weight of "Mrs. Average" did not change - neither in response to the sugar- nor in the aspartame sweetened drinks. 

Wtf? Sugar does not make you fat!? There are a couple of good reasons we got to be cautious with generalizing assessments like "sugary drinks are not the problem!":

1. 

   In contrast to the study Sartor et al. found that their participants gained 1kg of fat in only four weeks "on" Lucozade energy drinks | more

   Neither this study nor the previous studies measured the health-relevant changes in body composition of which the 2012 study by Sartor et al. clearly shows that they will occur if you simply add a bunch of sugary energy drinks to your diet (learn more).
2. With its 100% plain sugar content, the beverage the scientists used is not representative of the "average" soda. It is thus unwarranted to conclude that the lean, overweight and, in the study at hand, obese subjects would also be able to compensate for beverages with HFCS, dextrose or whatever other funky caloric sweeteners the industry uses.

Even if (2) was not true and similar compensatory effects wouldn't be observed with sweeteners, the data from the study at hand clearly weakens the "empty calories" argument. It does so, however, without being the first class acquittal Sugar Nutrition UK was probably hoping for when they decided to provide the financial means for this study.

References

• Reid M, Hammersley R, Hill AJ, Skidmore P. Long-term dietary compensation for added sugar: effects of supplementary sucrose drinks over a 4-week period. Br J Nutr. 2007 Jan;97(1):193-203.
• Reid M, Hammersley R, Duffy M. Effects of sucrose drinks on macronutrient intake, body weight, and mood state in overweight women over 4 weeks. Appetite. 2010 Aug;55(1):130-6.
• Reid M, Hammersley R, Duffy M, Ballantyne C. Effects on obese women of the sugar sucrose added to the diet over 28 d: a quasi-randomised, single-blind, controlled trial. Br J Nutr. 2013 Oct 29:1-8. [Epub ahead of print]

Water or Diet Soda - What's the Better Diet Beverage? Study Confirms Fake Sweetness Promotes Weight & Waist Loss, Decreases Hunger, Blood Pressure, Cholesterol & Trigs

There is one thing that's not debatable, compared to regular coke, diet coke is a diet beverage.

I am probably repeating myself, when I tell you that there are still many people out there who don't understand that it makes a fundamental difference if you are looking at potential pro-obesogenic effect of non-nutritive sweeteners (NNS) in an energy restricted vs. ad-libitum diet scenario. In view of the discussions revolving around the last article on a similar matter, I still thought it was prudent to mention that something that could potentially increase the cravings for sweets is not going to make you fat, if you don't give in to the urges.

Apropos urges, if you look at the abstract of the study I am about to discuss in today's SuppVersity article, you will realize that this effect does not existent.

You can learn more about sweeteners at the SuppVersity

Unsatiating Truth About Sweeteners?

Will Artificial Sweeteners Spike Insulin?

Sweeteners & the Gut Microbiome Each is Diff.

Sweeter Than Your Tongue Allows!

Stevia, Much More Than Sweet?

Artif. Sweetened Foods Help Weight Loss!

In fact, a brief glimpse at the data scientists from the University of Colorado it's obvious that the exact opposite happens. After 12 weeks on  those of the 158 subjects who had been randomized to consume at least 24 fluid ounces of a non-nutritive sweetened beverage of their choice per day had not jus lost 46% more body weight than their peers who had been confined to water for 12 weeks, they also experienced a slight decline in hunger.

Figure 1: Changes in body weight, waist circumference & hunger in the course of the 12-week study (Peters. 2014)

In the water only group, on the other hand, the perceived desire to eat e the water drinkers increased in the course of the study period - certainly a potential reason they lost ~2kg less body weight than their peers did over the course of the 12-week study.

There are a few drawbacks to the study you should know of: Firstly, 12 weeks is not a very long study period and someone who is obese would have to benefit for at least 50 weeks to lose more than the pathetic 6kg of weight the subjects in the study and hand lost. Secondly, the results cannot be used in non-diet contexts - if there is no calorie restriction, the effects may be very different. Thirdly, the subjects were all already non-nutritive sweetener consumers. For someone who is used to regular coke the effects may thus not be as pronounced. And fourth- and lastly, the authors are stuck for an answer to the most important question: Why does it work? In know this is a typical physicist thing, but as long as we can't explain it, it does not really exist for us ;-)

As the data in Figure 2 goes to show you, this weight loss benefit was not bought dearly! On the contrary, the non-nutritive sweetener group who had received gift coupons from the Coca-Cola Company, PepsiCo and Dr Pepper Snapple Group that were redeemable for bottled water or NNS beverages at retail stores, didn't just record greater weight loss and less hunger, they had also higher reductions in blood pressure, waist circumference, total and LDL cholesterol and triglycerides.

Figure 2: Changes in systolic BP, total, LDL and HDL cholesterol and triglycerides (Peters. 2014)

Personally I would exclude that this is in any way directly related to the use of dietary sweeteners. reducing effects of the non-nutritive sweeteners may thus eventually tipped the balance in favor of the aspartame, acesulfam-k and stevia group.

What's much more likely is that these additional benefits are - just like the increased weight loss - attributable to an increased adherence to the energy deficient diet and a lower number of (sweet) cheat meals. In combination with the ~30min of extra physical activity the "diet coke junkies" performed, the appetite suppressive effects may thus well explain the statistically significant advantage the scientists from the University of Colorado and the Temple University recorded in their latest study.

Yes, some sweeteners can increase the amount of insulin your pancreas produces, but there are only few scenarios in which these effects could make you fat - and dieting is not one of them | learn more

Bottom line: If we assume that none of the sponsors American Beverage Association messed with the objectively measured results of the study at hand, we are dealing with another experimental confirmation of what the majority of fitness, bodybuilding and fitness competitors have been saying for years: "Diet coke & co help me stick to my diet and everything that helps me stick to my diet will help me to step on stage in picture perfect form." I am not sure why this sounds incredible do some people, but the way you see fitness forum visitors keep accusing artificially sweetened beverages for their own failure is another hilarious instance of the scapegoatism millions of failed dieters use to find ever-new excuses for their own mistakes and shortcomings.

Diet Coke & Liver Damage? Long Term Very High Dose Aspartame Consumption Impairs Antioxidant Defense of Rat Livers.

The ever-growing group of health conscious costumers is rightly very skeptical of artificial sweeteners in general and Aspartame in particular. A recent study (Abhilash. 2011) done by scientists from the Mahatma Gandhi University in Kottayam, Kerala, India, seems to rectify this attitude.

The scientists fed rats drinking water that contained either no, i.e. 0mg, 500mg or 1.000mg aspartame per kg body weight day for a period of 160days. The rats from the 1.000mg/kg group showed...

[...] a significant increase in activities of alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and γ- glutamyl transferase (GGT). The concentration of reduced glutathione (GSH) and the activity of glutathione peroxidase (GPx), and glutathione reductase (GR) were significantly reduced in the liver of rats that had received aspartame (1000mg/kg.b.wt).

The presence of "leukocyte infiltration in aspartame-treated rats (1000mg/kg.b.wt)" further underlines that high dose aspartame consumption over a period of 160 days induced "hepatocellular injury and alterations in liver antioxidant status" by increasing the detoxification burden on the liver to supra-physiological levels.

Yet, what does that mean for the average consumer? Let us put the figures into perspective: 1 liter of diet coke contains about 390mg of aspartame. The rats in the high dose aspartame group in the study (which is the only one where anti-oxidant status fell enough to induce histological side effects) received 1.000mg/kg of aspartame per day. In human equivalent dosages (HED), this is 162mg/kg, which would be 11.35g of aspartame or 29 l diet coke for a 70kg adult. Not that I want to trivialize the possible liver toxicity due to aspartame consumption, but let's be honest: you would probably long have died from hyperhydration before you would notice any of the toxic effects induced by the consumption of an artificial sweetener, which - far from being healthy - is yet not as toxic as some health-fetishists would have it.

In spite of the fact that a diet coke here and there won't kill you, you should still ask yourselves, whether or not you really need this "spawn" of a society where we want all the convenience and (unnaturally sweet) taste of unhealthy foods without the negative consequences for our health? I mean, you obviously chose the "diet" version because you want to avoid sugar; but do you still want the sweet taste, which (at least for some artificial sweeteners, eg. Nakagawa. 2009) has been shown to increase insulin secretion even in the absence of direct beta cell stimulation!? If you are willing to accept this compromise and do not care about the other chemicals your average can of diet coke "nourishes" you with, fine! But do not tell me later on, I had told you that diet coke was good for you ;-)

Coke vs. Diet Coke vs. Milk - The "Unhealthy Beverage Shoot-Out": Milk Reduces, Coke Increases Visceral Fat. Dreaded Diet Coke on Par With Plain Water

Image 1: I guess plastic dolls don't care about "fat" anyway.. so why would they drink diet coke, then?

I assume that at least some of you have read the Ask Dr. Andro post from August, 21, 2010, "Are Colostrum and Milk Products Healthy Muscle Builders, a Waste of Money or Toxic Waste?" As the title already suggests, the focus of this article was on milk / milk products as muscle builders and before I came across a recent study that was conducted by a group of scientists from Denmark, I would have called anyone who tells overweight persons to drink skimmed milk instead of water a total moron ... well, I guess, learning never stops ;-)

The VAT burning effects of skimmed milk

The Danish researchers conducted a randomized controlled trial to investigate the effects of different non-alcoholic beverages on the body composition of 60 healthy, non-diabetic subjects with a BMI (kg/m²) between 26 and 40 (age 20-50y). In the absence of any other dietary (or exercise) interventions, 45 of the subjects had consume 1l of either regular Coca Cola (yes it was the original ;-), diet Coke or Milk in addition to their regular water intake. The remaining 15 subjects who consumed nothing but water served as a control.

Figure 1: Macronutrient (g/100ml) and energy content (kj/day) of the three non-water beverages in the study (data adapted from Maersk. 2011)

If you look at the macronutrient composition (I know it is a joke to talk about a "composition" in the case of coke and diet coke ;-), it appears be quite obvious that neither of the two "high caloric beverages" would be particularly helpful in losing weight... so that this would leave us with the question, whether diet coke is - as many people claim - more fattening than water.

Figure 2: Changes in fat mass of subjects who consumed diet coke, milk or water over the course of the 6 months trial expressed relative to subjects in the regular coke group; * p < 0.05 (calculated based on Maersk. 2011)

If we take a closer look at the real effect of the different beverages, we will yet have to admit that we may have jumped to conclusion, here. After all, milk not water or diet coke was the only beverage the consumption of which lead to statistically significant reductions in the size of the unhealthy visceral fat in the 15 subjects of the respective arm of the trial. And of the three "coke replacements" that were tested, it was also the one that induced the most profound reductions in liver fat.

Figure 3: Changes in body weight, total fat mass, subcutaneous abdominal adipose tissue (SAAT), visceral fat to SAAT ratio, lean mass and bone mass after 6 months (data adapted from Maersk. 2011)

If we now take a look at the overall effects on body composition and bone mass, it does yet become clear that the often touted general weight-loss effects of low-fat dairy consumption are not supported by the data, as there were no "statistical significant differences" in either total body, or total fat weight between the groups. If we do yet discard the statistical shenanigan and use eyes instead of our calculators, I would say that there is a certain pattern, which - aside from the VAT burning effects of skimmed milk - fits very well, with what we did expect: Regular Coke is fattening, especially in the ectopic visceral fat depots, water is the best option for overall fat loss and milk has the advantage of helping with the retention or even the accrual of lean muscle and bone mass.

"And what about diet coke? Is it really benign?"

I know that this question is preying on your minds, right now: "Could it really be that the aspartame sweetened poison is not fattening? I mean doesn't it spike insulin?" ... based on the body composition data, the answer would be "Yes! 1l of aspartame sweetened diet coke per day does not hinder weight loss." If we do yet also consider a few other variables and - once again - don't rely all too much on the power of statistics, it does appear as if there exists the remote possibility that the difference between diet coke and water is more profound than the 15kj energy difference would suggest.

Figure 4: Changes in markers of blood glucose management and blood pressure after 6 months (data adapted from Maersk. 2011)

While none of the blood sugar related effects you see in figure 4 reached statistical significance, the group averages would suggest that drinking diet coke is associated with a reduction in blood glucose, basal insulin levels, no increase in HOMA-IR - all markers of improved blood sugar management. Moreover, the blood pressure of the diet coke consumers decreased to a similar and statistically significant (compared to regular coke) extent as the blood pressure of the subjects who consumed skimmed milk.

Figure 5: Changes in leptin, total cholesterol, triglycerides and HDL after 6 months (data adapted from Maersk. 2011)

A similar picture emerges if we take a final look at the lipid panels of the subjects, though only the changes in total cholesterol and triglycerides reached statistical significance (for diet coke, milk, and water compared to regular coke), it does nevertheless go against the vilification of diet coke that the diet coke consumers were the only ones, where the leptin levels decreased, had the greatest decrease in total cholesterol (which also explains that they had the lowest increase in HDL) and a similar profound reduction in triglycerides as the water consumers.

"So diet coke is better than water?"

Before you do now start to pound liter after liter of diet coke every day, let me put out one, or rather two hypothesis that could well explain the previously mentioned differences:

1. Although the the lifestyle changes of the subjects regarding diet and physical activity were monitored at baseline, after 3 mo, and at the end of the intervention with the use of a 7 - d dietary record and a validated questionnaire concerning physical activity at work, during leisure time, and during sports, this was no clinical setting, where the scientists fed identical diets (except for the beverages) to every participant. The subjects in the diet coke group could have thusly simply have satisfied their sweet tooth by consuming the brown brew and could consequently have reduced their intake of sugary foods. That alone could explain the mostly statistically non-significant differences between the diet coke and the
    
2. The "no-calorie" issue aside, diet coke is also caffeinated and as a regular visitor of this blog you will be well aware of the beneficial metabolic effects of caffeine. And though the 1L of coke contain only 131mg of caffeine, this would probably go as a "statistical significant difference" compared to water - and I guess I do not have to repeat that the latter was not the case for the previously discussed "advantages".

In view of the fact that this study is not suitable to answer the question whether diet coke or similar artificially sweetened beverages would hamper weight loss or induce weight gain in subjects on absolute identical diets, it goes to show that a) 1L of coke light is way better than 1L of real coke and that b) the consumption of 1L of skimmed milk exerts an unexpected beneficial effect on visceral adipose tissue - and that in the absence of any other dietary intervention... that does now make me wonder what the results would have looked like if the milk had not been skimmed, but full-fat, but I guess it will still take a few years until the paradigms have shifted and we will eventually see scientists hypothesize that full-fat or even raw milk could in fact be healthy ;-)