Consumption of 100% Fruit Juice and Body Weight in Children and Adults: A Systematic Review and Meta-Analysis

Michelle Nguyen; Sarah E Jarvis; Laura Chiavaroli; Sonia Blanco Mejia; Andreea Zurbau; Tauseef A Khan; Deirdre K Tobias; Walter C Willett; Frank B Hu; Anthony J Hanley; Catherine S Birken; John L Sievenpiper; Vasanti S Malik

doi:10.1001/jamapediatrics.2023.6124

. 2024 Jan 16;178(3):237–246. doi: 10.1001/jamapediatrics.2023.6124

Consumption of 100% Fruit Juice and Body Weight in Children and Adults

A Systematic Review and Meta-Analysis

Michelle Nguyen ¹, Sarah E Jarvis ¹, Laura Chiavaroli ^1,^2,³, Sonia Blanco Mejia ^1,², Andreea Zurbau ^1,², Tauseef A Khan ^1,², Deirdre K Tobias ^4,⁵, Walter C Willett ^4,⁶, Frank B Hu ^4,^6,⁷, Anthony J Hanley ^1,^8,⁹, Catherine S Birken ^1,^10,¹¹, John L Sievenpiper ^1,^2,^3,^12,¹³, Vasanti S Malik ^1,^3,^✉

¹Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

²Toronto 3D Knowledge Synthesis & Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St Michael’s Hospital, Toronto, Ontario, Canada

³Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada

⁴Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

⁵Division of Preventive Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

⁶Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts

⁷Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts

⁸Division of Endocrinology, University of Toronto, Toronto, Ontario, Canada

⁹Leadership Sinai Centre for Diabetes, Mount Sinai Hospital, Toronto, Ontario, Canada

¹⁰Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada

¹¹Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Ontario, Canada

¹²Division of Endocrinology & Metabolism, St Michael’s Hospital, Toronto, Ontario, Canada

¹³Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada

Accepted for Publication: November 13, 2023.

Published Online: January 16, 2024. doi:10.1001/jamapediatrics.2023.6124

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Corresponding Author: Vasanti S. Malik, MSc, ScD, Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King’s College Circle, Toronto, ON M5S 1A8, Canada (vasanti.malik@utoronto.ca).

Author Contributions: Ms Nguyen had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Nguyen, Chiavaroli, Willett, Hu, Birken, Malik.

Acquisition, analysis, or interpretation of data: Nguyen, Jarvis, Chiavaroli, Blanco Mejia, Zurbau, Khan, Tobias, Hu, Hanley, Birken, Sievenpiper, Malik.

Drafting of the manuscript: Nguyen, Khan.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Nguyen, Jarvis, Chiavaroli, Zurbau, Khan, Tobias, Willett.

Administrative, technical, or material support: Blanco Mejia, Birken.

Supervision: Khan, Hanley, Birken, Sievenpiper, Malik.

Conflict of Interest Disclosures: Dr Chiavaroli reported being a Mitacs-Elevate postdoctoral fellow jointly funded by the Government of Canada and the Canadian Sugar Institute and being previously employed as a casual clinical coordinator at INQUIS Clinical Research Ltd (formerly Glycemic Index Laboratories Inc), a contract research organization, during the conduct of the study. Dr Zurbau reported being a part-time research associate at INQUIS Clinical Research Ltd, a contract research organization and receiving consulting fees from Glycemic Index Foundation. Dr Khan reported receiving research support from the Canadian Institutes of Health Research, the International Life Science Institute, and National Honey Board and funding from the Toronto 3D Knowledge Synthesis and Clinical Trials Foundation. Drs Tobias, Hu, and Malik reported receiving funding from the National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (grant RO1DK125803) for related research during the conduct of this study. Dr Hanley reported receiving research grants from the Canadian Institutes of Health Research, Diabetes Canada, the Canadian Foundation for Innovation, the Canada Research Chairs Program, and the Canadian Foundation for Innovation and Dairy Farmers of Canada. Dr Sievenpiper reported receiving research support from the Canadian Foundation for Innovation, Ontario Research Fund, Province of Ontario Ministry of Research and Innovation and Science, Canadian Institutes of Health Research, Diabetes Canada, American Society for Nutrition, International Nut and Dried Fruit Council Foundation, National Honey Board (US Department of Agriculture), Institute for the Advancement of Food and Nutrition Sciences (formerly ILSI North America), Pulse Canada, Quaker Oats Center of Excellence, The United Soybean Board, The Tate and Lyle Nutritional Research Fund at the University of Toronto, The Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), The Plant Protein Fund at the University of Toronto (a fund which has received contributions from International Flavors & Fragrances), and The Nutrition Trialists Network Research Fund at the University of Toronto (a fund established by an inaugural donation from the Calorie Control Council); receiving food donations to support randomized clinical trials from the Almond Board of California, California Walnut Commission, Peanut Institute, Barilla, Unilever/Upfield, Unico/Primo, Loblaw Companies, Quaker, Kellogg Canada, Danone, Nutrartis, Soylent, and Dairy Farmers of Canada; receiving travel support, speaker fees and/or honoraria from ASN, Danone, Dairy Farmers of Canada, FoodMinds LLC, Nestlé, Abbott, General Mills, Nutrition Communications, International Food Information Council, Calorie Control Council, International Sweeteners Association, International Glutamate Technical Committee, Phynova, Arab Beverages Association, and Brightseed; having had ad hoc consulting arrangements with Perkins Coie LLP, Tate & Lyle, and Inquis Clinical Research; being a former member of the European Fruit Juice Association Scientific Expert Panel and former member of the Soy Nutrition Institute Scientific Advisory Committee; being on the Clinical Practice Guidelines Expert Committees of Diabetes Canada, European Association for the study of Diabetes, Canadian Cardiovascular Society, and Obesity Canada/Canadian Association of Bariatric Physicians and Surgeons; serving as an unpaid member of the Board of Trustees and formerly served as an unpaid scientific advisor for the Carbohydrates Committee of the Institute for the Advancement of Food and Nutritional Sciences; and serving as a director at large of the Canadian Nutrition Society, founding member of the International Carbohydrate Quality Consortium, executive board member of the Diabetes and Nutrition Study Group of the European Association for the Study of Diabetes, and director of the Toronto 3D Knowledge Synthesis and Clinical Trials Foundation outside the submitted work. Dr Malik reported receiving funding from the Canada Research Chairs Program; Connaught New Researcher Award, University of Toronto; The Joannah & Brian Lawson Centre for Child Nutrition, University of Toronto; Temerty Faculty of Medicine Pathway Grant, University of Toronto; and the Canada Foundation for Innovation; Ontario Research Fund and serving as a consultant for the city and county of San Francisco for litigation related to health warning labels on sugar-sweetened beverages. No other disclosures were reported.

Funding/Support: This study was supported by funding from the Ontario Graduate Scholarship, Peterborough KM Hunter Charitable Foundation Graduate Award, Dalton Whitebread Scholarship Fund, and SMART Healthy Cities Trainee Award (Ms Nguyen).

Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

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Corresponding author.

PMCID: PMC10792499 PMID: 38227336

This systematic review and meta-analysis investigates the association between 100% fruit juice intake and body weight in children and adults.

Key Points

Question

What is the association between 100% fruit juice intake and body weight in children and adults?

Findings

This systematic review and meta-analysis of 42 eligible studies, including 17 among children (n = 45 851) and 25 among adults (n = 268 095), found a positive association between intake of 100% fruit juice and weight gain in children. Analysis of cohort studies in adults found a significant positive association among studies unadjusted for total energy, suggesting potential mediation by calories; an analysis of trials in adults found no significant association between 100% fruit juice consumption and body weight.

Meaning

Study findings support guidance to limit consumption of fruit juice to prevent the intake of excess calories and weight gain.

Abstract

Importance

Concerns have been raised that frequent consumption of 100% fruit juice may promote weight gain. Current evidence on fruit juice and weight gain has yielded mixed findings from both observational studies and clinical trials.

Objective

To synthesize the available evidence on 100% fruit juice consumption and body weight in children and adults.

Data Sources

MEDLINE, Embase, and Cochrane databases were searched through May 18, 2023.

Study Selection

Prospective cohort studies of at least 6 months and randomized clinical trials (RCTs) of at least 2 weeks assessing the association of 100% fruit juice with body weight change in children and adults were included. In the trials, fruit juices were compared with noncaloric controls.

Data Extraction and Synthesis

Data were pooled using random-effects models and presented as β coefficients with 95% CIs for cohort studies and mean differences (MDs) with 95% CIs for RCTs.

Main Outcomes and Measures

Change in body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was assessed in children and change in body weight in adults.

Results

A total of 42 eligible studies were included in this analysis, including 17 among children (17 cohorts; 0 RCTs; 45 851 children; median [IQR] age, 8 [1-15] years) and 25 among adults (6 cohorts; 19 RCTs; 268 095 adults; median [IQR] age among cohort studies, 48 [41-61] years; median [IQR] age among RCTs, 42 [25-59]). Among cohort studies in children, each additional serving per day of 100% fruit juice was associated with a 0.03 (95% CI, 0.01-0.05) higher BMI change. Among cohort studies in adults, studies that did not adjust for energy showed greater body weight gain (0.21 kg; 95% CI, 0.15-0.27 kg) than studies that did adjust for energy intake (−0.08 kg; 95% CI, −0.11 to −0.05 kg; P for meta-regression <.001). RCTs in adults found no significant association of assignment to 100% fruit juice with body weight but the CI was wide (MD, −0.53 kg; 95% CI, −1.55 to 0.48 kg).

Conclusion and Relevance

Based on the available evidence from prospective cohort studies, in this systematic review and meta-analysis, 1 serving per day of 100% fruit juice was associated with BMI gain among children. Findings in adults found a significant association among studies unadjusted for total energy, suggesting potential mediation by calories. Further trials of 100% fruit juice and body weight are desirable. Our findings support guidance to limit consumption of fruit juice to prevent intake of excess calories and weight gain.

Introduction

Consumption of 100% fruit juice can serve as a convenient means to meet daily fruit recommendations and offers many of the nutrients found in whole fruit including essential vitamins, antioxidants, and polyphenols that can contribute to a healthy dietary pattern.¹ However, there is concern that intake of 100% fruit juice may contribute to weight gain due to the high amounts of free sugars and energy.² These beverages contain little to no fiber compared with the whole fruit form, resulting in low satiety and greater ad libitum energy intake.^3,4 The current evidence on 100% fruit juice and weight gain has yielded mixed findings from both epidemiologic and clinical studies, possibly due to differences in fruit juice types, consideration of total energy as a potential mediator, and variable adjustment for important potential confounders.

Further, international guidelines on 100% fruit juice are inconsistent. The Dietary Guidelines for Americans permits 100% fruit juice as a serving of fruit and recommends limiting added sugars, which does not include naturally occurring sugars found in 100% fruit juice.⁵ The World Health Organization⁶ and Canada’s Dietary Guidelines⁷ recommend limiting free sugars, including those from 100% fruit juice, to less than 10% of total energy. The American Academy of Pediatrics⁸ provides separate recommendations according to age groups in children over concerns for dental caries and obesity. Nearly 50% of children and adolescents consume at least 1 serving of fruit juice a day,⁹ with younger children having the highest consumption rates.¹⁰ With the rising overweight and obesity rates in children and adults worldwide,¹¹ evidence-based recommendations for 100% fruit juice consumption are needed. The totality of the evidence needs to be evaluated to inform public policy and clinical practice guidelines. Thus, we conducted a comprehensive systematic review and meta-analysis evaluating 100% fruit juice consumption and body weight in children and adults.

Methods

Protocol and Registration

We followed the Cochrane Handbook for Systematic Reviews of Interventions¹² to conduct this systematic review and meta-analysis. Results are reported in compliance with Meta-analysis of Observational Studies in Epidemiology (MOOSE)¹³ and Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)¹⁴ reporting guideline. The protocol was prospectively registered in PROSPERO. Detailed methods are outlined in the eMethods in Supplement 1.

Search Strategy and Study Selection

We searched MEDLINE, Embase, and Cochrane databases from inception through to May 18, 2023. The full search strategy is presented in eTable 1 in Supplement 1.

Our review included prospective cohort studies of at least 6 months and randomized clinical trials (RCTs) with interventions lasting at least 2 weeks assessing 100% fruit juice consumption and weight gain in children and adolescents (<18 years) and adults (≥18 years). We defined 100% fruit juice as fruit juices with no added sugar, explicitly stated as a 100% fruit juice, or otherwise described. Studies that also combined vegetable juices or sugar-sweetened beverages such as sodas or fruit drinks were excluded. In RCTs, 100% fruit juice was compared with noncaloric controls (ie, water or a nonnutritive sweetened beverage such as a diet soda sweetened with nonnutritive sweeteners such as aspartame or sucralose) or with the usual diet alone. Studies with an isocaloric control, a multimodal intervention, or combined 100% fruit juice with other foods, supplements, or lifestyle factors were excluded. This meta-analysis was not able to assess for differences in race or ethnicity due to the lack of detailed information provided from the original studies. Therefore, subgroup analyses by study location were performed, which may provide some context into the generalizability of the findings.

Data Extraction and Quality Assessment

Data from eligible studies were extracted by 2 independent reviewers (M.N. and S.E.J.). The risk of bias was assessed using the Newcastle-Ottawa Scale¹⁵ for prospective cohort studies and the Cochrane Risk of Bias¹² for RCTs.

Statistical Analysis

For prospective cohort studies in children and adults, it was necessary to perform data transformations to standardize the outcome measures and units for meta-analysis. A detailed table of the transformations is presented in eTable 2 in Supplement 1. Our primary outcome was change in BMI (calculated as weight in kilograms divided by height in meters squared) for children, or body weight (in kilograms) for adults, per every 8-oz (237-mL) serving per day increment of 100% fruit juice during the duration specified in each study. Several studies reported the change in 100% fruit juice intake in relation to the change in weight, thus a change vs change meta-analysis was conducted separately. Due to the potential mediation of energy intake on the association of 100% fruit juice and weight gain, our primary analysis used estimates not adjusted for total energy intake when available, and a separate meta-analysis using estimates adjusted for total energy intake was conducted. We conducted an additional analysis extrapolating the change in BMI or body weight to a 1-year period assuming a linear trajectory. For prospective cohort studies in children, we conducted a separate meta-analysis assessing the association of 100% fruit juice with BMI z score.

Data analyses were conducted using Stata, version 16.1 (StataCorp). Data were pooled for each outcome using the DerSimonian and Laird random-effects model. Inverse-variance–weighted (fixed-effect) models were also conducted. Pooled results are expressed as β coefficients with 95% CIs for prospective cohort studies and mean difference (MD) with 95% CIs for RCTs. Dose-response analysis was modeled to assess linear and nonlinear dose-response relationships.¹⁶ We assessed between-study heterogeneity using the Cochrane Q statistic quantified by the I² statistic and P value for heterogeneity.¹² Sources of heterogeneity were explored through sensitivity analysis, where individual studies were systematically removed from the meta-analysis and the pooled-effect estimate recalculated. Sources of heterogeneity were additionally explored through a priori subgroup analyses. Publication bias was assessed through visual inspection of funnel plots and Eggers and Begg tests.^17,18 In the presence of publication bias, the trim-and-fill method was used.¹⁹

The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.²⁰ To complement the GRADE approach, NutriGRADE was additionally conducted to take into account nutrition research specific considerations.²¹

Results

Search Results

Our search identified 42 articles included in our final review. Of these, 17 prospective cohort studies were identified in children (45 851 children), reporting 23 comparisons.^{22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38} No RCTs were identified among children. A total of 25 studies were identified for adults (268 095 adults), with 6 prospective cohort studies with 8 comparisons,^{39,40,41,42,43,44} and 19 RCTs.^{45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63} The screening and exclusion flowchart is presented in eFigure 1 in Supplement 1. The full list of excluded studies is presented in eTable 3 in Supplement 1.

Study Characteristics

The study characteristics of the included prospective cohort studies in children and adults and RCTs in adults are summarized in Table 1 and Table 2, respectively, with the full study characteristics provided in eTables 4 to 6 in Supplement 1. The majority of prospective cohort studies in children were conducted in North America with median (IQR) baseline age of 8 (1-15) years and median (IQR) study duration of 4 years (8 months-10 years). Prospective cohort studies in adults were conducted in North America or Europe with a median (IQR) age of 48 (41-61) years and median (IQR) study duration of 3 (2-24) years. The majority of RCTs in adults were conducted in Europe or Asia with a median (IQR) age of 42 (25-59) years and median (IQR) study duration of 6 (2-12) weeks. All trials were feeding trials, where participants were provided 100% fruit juice in the form of pomegranate, berries, tart cherry, apple, citrus, or grape juice. Comparisons included with the standard diet alone, water, or nonnutritive sweetened beverages.

Table 1. Characteristics of Included Prospective Cohort Studies.

Study characteristics^a	Cohort studies in children	Cohort studies in adults
No. of cohorts	17 (23 Comparisons)	6 (8 Comparisons)
Study location	North America (n = 10) Europe (n = 5), Australia (n = 1), South America (n = 1)	North America (n = 4), Europe (n = 2)
Duration (range)	4 y (8 mo-10 y)	3 y (2-24 y)
Sample size (range)	1038 (158-14 918)	29 037 (810-124 988)
Baseline age (range), y	8 (1-15)	48 (41-61)
Baseline BMI (range)^b	17.4 (16.0-20.2)	26.5 (24.9-33.1)
Dietary assessment method	FFQs (n = 10), 24-h recalls (n = 4), food records (n = 3)	FFQs (n = 5), 24-h recalls (n = 1)
Outcome assessment method	Measured by investigators (n = 13), self-report (n = 4)	Measured by investigators (n = 4), self-report (n = 2)
Adjusted for energy intake	Unadjusted (n = 13), adjusted (n = 4)	Unadjusted (n = 3), adjusted (n = 3)

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Abbreviations: BMI, body mass index; FFQ, Food frequency questionnaire.

^{^a}

Medians.

^{^b}

Calculated as weight in kilograms divided by height in meters squared.

Table 2. Characteristics of Included Randomized Clinical Trials (RCTs) in Adults.

Study characteristics^a	RCTs in adults
No. of RCTs	19
Study location	North America (n = 4), Europe (n = 7), Asia (n = 6), South America (n = 1), New Zealand (n = 1)
Study design	Parallel (n = 18), crossover (n = 1)
Duration (range), wk	6 (2-12)
Sample size (range)	42 (10-72)
Baseline age (range), y	42 (25-59)
Baseline BMI (range)^b	28.6 (22.3-35.5)
Health status	Healthy (n = 6), overweight (n = 4), PCOS (n = 2), MetS (n = 2), T2D (n = 3), pre-CVD (n = 1), gout (n = 1)
Intervention	100% Fruit juice; pomegranate (n = 8), goji (n = 2), berry (n = 3), citrus (n = 2), apple (n = 2), cherry (n = 1), grape (n = 1)
Control	Diet alone (n = 9), water (n = 7), nonnutritive sweetened beverage (n = 3)

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Abbreviations: BMI, body mass index; CVD, cardiovascular disease; MetS, metabolic syndrome; PCOS, polycystic ovary syndrome; T2D, type 2 diabetes.

^{^a}

Medians.

^{^b}

Calculated as weight in kilograms divided by height in meters squared.

Risk of Bias

The risk of bias for prospective cohort studies assessed through the Newcastle-Ottawa Scale is presented in eTable 7 in Supplement 1. All studies received a score of 6 or greater, denoting high-quality studies. However, only 5 of 17 cohorts in children and 5 of 6 cohorts in adults used a change vs change analysis. The risk of bias for RCTs in adults assessed through the Cochrane Risk of Bias tool is presented in eFigures 2 and 3 in Supplement 1. The overall risk of bias for all domains tended to be low or unclear, suggesting low risk of bias.

Consumption of 100% Fruit Juice and Body Weight in Children

Prospective Cohort Studies

Figure 1 presents the association between each additional serving per day in 100% fruit juice and change in BMI based on 23 comparisons from 16 cohorts (n = 56 399). Pooled estimates using a random-effects model showed a 0.03 (95% CI, 0.01-0.05) higher BMI for every 8-oz serving per day. Substantial between-study heterogeneity was observed in the analysis (I² = 85%; P for heterogeneity <.001). Results from the inverse-variance–weighted model showed a 0.001 (95% CI, −0.002 to 0.01) BMI gain. No significant association was found for the change in 100% fruit juice intake with concomitant change in BMI (0.01; 95% CI, −0.03 to 0.04) (eFigure 4 in Supplement 1). When using the studies’ energy-adjusted estimates and scaled to a 1-year period, the positive association remained (eFigures 5 and 6 in Supplement 1). In our analysis of BMI z score, each additional serving per day in 100% fruit juice was associated with a 0.01 (95% CI, 0.001-0.02) higher BMI z score (eFigure 7 in Supplement 1).

Consumption of 100% Fruit Juice and Body Weight in Adults

Prospective Cohort Studies

Figure 2 presents the association between each additional serving per day in 100% fruit juice and change in body weight based on 8 comparisons from 6 cohorts (n = 267 362). Pooled estimates using a random-effects model showed no significant association for body weight gain (0.07 kg; 95% CI, −0.06 to 0.20 kg). Substantial between-study heterogeneity was observed in the analysis (I² = 97%; P for heterogeneity <.001). Results from the inverse-variance–weighted model showed a 0.10 kg (95% CI, 0.08-0.12 kg) higher body weight for every 8-oz serving per day. Longitudinal increases in 100% fruit juice were associated with concomitant body weight gain in our change vs change analysis (0.03 kg; 95% CI, 0.01-0.06 kg), inverse-variance–weighted model was similar with a narrow CI (eFigure 8 in Supplement 1). No significant association was found when using energy-intake adjusted models or scaled to a 1-year period (eFigures 9 and 10 in Supplement 1).

RCTs

Figure 3 presents the association of 100% fruit juice vs noncaloric and usual diet controls with body weight change in 19 RCTs (n = 733). Pooled-effect estimates using a random-effects model showed no significant association of 100% fruit juice consumption with body weight over a median of 6 weeks (MD, −0.53 kg; 95% CI, −1.55 to 0.48 kg). Substantial between-study heterogeneity was observed in the analysis (I² = 95%, P for heterogeneity <.001). The inverse-variance–weighted model similarly showed no significant outcome.

Sensitivity and Subgroup Analysis

Sensitivity analysis by systematically removing individual studies and recalculating the pooled-effect estimate did not change the overall significance, direction, or heterogeneity of the pooled estimates for any of our meta-analyses (eFigures 11-13 in Supplement 1).

Subgroup analysis for prospective cohort studies in children is presented in eFigure 14 in Supplement 1. Subgroup differences were observed by age of study population, where younger children (<11 years) showed a greater BMI gain (0.15; 95% CI, 0.05-0.24) than older children (≥11 years; −0.001; 95% CI, −0.01 to 0.01; P for meta-regression <.001). Statistically different subgroups were also found when age was further stratified according to dietary reference intake age groups.⁶⁴ Children 8 years and younger showed the greatest BMI gain per serving of 100% fruit juice (0.15; 95% CI, 0.01-0.29), followed by children aged 9 to 13 years (0.01; 95% CI, −0.01 to 0.03), and children older than 14 years (−0.10; 95% CI, −0.30 to 0.10; P for meta-regression <.03). Cohort studies^{22,23,24,25,26,27,29,32,33,34,36,37,38} in children that did not adjust for total energy intake showed a positive association for juice with body weight (0.05; 95% CI, 0.03-0.07), whereas studies^28,30,31,35 that adjusted for energy intake found no significant association (−0.01; 95% CI, −0.06 to 0.04; P for meta-regression = .02). Cohort studies^{22,23,25,26,27,28,30,32,33,34,35,37,38} where the outcome was measured by investigators showed greater BMI gain (0.11; 95% CI, 0.05-0.17) than self-reported studies^24,29,31,36 (−0.001; 95% CI, −0.001 to 0.01; P for meta-regression <.001). Cohort studies conducted in South America³³ (0.15; 95% CI, 0.10-0.20) showed a significant BMI gain, whereas cohort studies conducted in North America^{22,23,24,28,30,31,32,34,35,36} (0.02; 95% CI, −0.001 to 0.04), Europe^{25,26,27,29,38} (0.03; 95% CI, −0.03 to 0.08), and Australia³⁷ (0.37; 95% CI, −0.15 to 0.89) found no significant association (P for meta-regression =.001). Subgroup analysis for prospective cohort studies in adults is presented in eFigure 15 in Supplement 1. Cohort studies^40,42,44 that did not adjust for total energy intake showed a positive association for juice with body weight (0.21 kg; 95% CI, 0.15-0.27 kg), whereas studies^39,41,43 that adjusted for energy intake found an inverse association (−0.08 kg; 95% CI, −0.11 to −0.05; P for meta-regression <.001). Significant differences were also found for study location with studies conducted in North America^39,40,42,44 (0.14 kg; 95% CI, 0.02-0.26) showing significant body weight gain, whereas no significant association was observed among studies conducted in Europe^41,43 (−0.15 kg; 95% CI, −0.37 to 0.08; P for meta-regression = .04). There were no significant subgroup differences found for RCTs in adults (eFigures 16 and 17 in Supplement 1). However, when stratified by dose, less than 1 serving per day was significantly associated with weight loss (MD, −1.23 kg; 95% CI, −2.41 to −0.05 kg), 1 to 2 servings per day showed no significant outcome (MD, −0.66 kg; 95% CI, −3.02 to 1.70 kg), and more than 2 servings per day were significantly associated with weight gain (MD, 0.46 kg; 95% CI, 0.30-0.62 kg; P for meta-regression = .24).

Dose Response

Dose-response analyses are shown in eFigures 18 through 28 in Supplement 1. Although dose-response analyses were conducted for cohort studies in adults, the comparisons were based on 2 cohorts, thus the results cannot be interpreted as representative. No evidence of a dose-response association was found for any outcome.

Publication Bias

Visual inspection of the funnel plot and Egger test showed evidence of publication bias in cohort studies in children (P = .03) (eFigure 29 in Supplement 1). The trim-and-fill method imputed 2 studies; however, it did not change the overall inference and conclusion, suggesting no meaningful influence of publication bias in these analyses (eFigure 30 in Supplement 1). There was no evidence of publication bias in cohorts and trials in adults (eFigures 31 and 32 in Supplement 1).

GRADE Assessment

The GRADE assessments are presented in eTables 8 and 9 in Supplement 1. The certainty of evidence for 100% fruit juice and BMI and body weight for cohort studies in children and adults were graded as “very low.” RCTs in adults were graded as “low.” NutriGRADE assessments graded cohort studies in children as moderate, cohort studies in adults as low, and RCTs in adults as moderate quality (eTables 10 and 11 in Supplement 1).

Discussion

Our systematic review and meta-analysis of prospective cohort studies in children demonstrated a positive association between 100% fruit juice consumption and change in BMI (0.03; 95% CI, 0.01-0.05), with younger children showing higher BMI for each additional serving per day than older children (0.15; 95% CI, 0.05-0.24 and −0.001; 95% CI, −0.01 to 0.01, respectively). Although pooled effects from prospective cohort studies in adults found no significant association overall (0.07 kg; 95% CI, −0.06-0.20 kg), studies that were unadjusted for energy intake were significantly associated with body weight gain (0.21 kg; 95% CI, 0.15-0.27 kg), and studies adjusted for energy intake were inversely associated with body weight gain (−0.08 kg; 95% CI, −0.11 to −0.05 kg). RCTs in adults found no significant association of 100% fruit juice consumption with body weight, but the CI was wide and included the association seen in the cohort studies (MD, −0.53 kg; 95% CI, −1.55 to 0.48). No significant differences between juice types were observed.

Findings in the Context of Existing Literature

To date, the existing evidence on 100% fruit juice and body weight have been limited with conflicting findings. Three reviews of cohort studies in children found no significant association between 100% fruit juice and BMI, 2 of which, however, were qualitative and not meta-analyses,^31,65 and another primarily assessed cross-sectional studies.⁶⁶ No reviews of RCTs in children were conducted due to the absence of studies. Our findings are in agreement with a meta-analysis conducted in 2017 that found a positive association between 100% fruit juice and BMI in younger children.⁶⁷ A systematic review of cohort studies in adults found evidence suggesting weight gain,⁶⁸ whereas meta-analyses of RCTs in adults found no significant outcome.^69,70,71,72 Our comprehensive systematic review and meta-analysis provides a novel analysis of 100% fruit juice and weight gain assessing children and adults using data from both prospective cohort studies and RCTs.

Our meta-analysis of cohort studies in children found a positive association between 100% fruit juice and BMI. Notably, when stratified by the median age, our analyses suggested that younger children (<11 years) showed a greater BMI gain per every 8-oz additional serving per day of 100% fruit juice than the older children (≥11 years). The association remained when further stratified by the daily reference intake age groups. The youngest age group of children, 8 years or younger, had the greatest BMI gains, followed by children aged 9 to 13 years, and children 14 years and older. An 8-oz serving of 100% fruit juice, or a typical glass, would contribute to a larger proportion of daily energy in younger children than it would in older children. Our findings are in line with American Academy of Pediatrics guidelines that children younger than 6 years should consume less than a glass of fruit juice per day.⁸ Additional concerns have been raised that the early age of fruit juice introduction may lead to an increased risk for overweight and obesity in later childhood due to increased preference for sweet foods.^34,73 Thus, delaying the introduction of 100% fruit juice in young children, moderating serving sizes, and favoring whole fruit is recommended. Although the effect sizes are modest, small gains in BMI over time may substantiate over the life course; therefore, limiting intake of fruit juice among children is an important strategy for them to develop healthy weight trajectories.

Our findings from prospective cohort studies in adults suggest that the association between 100% fruit juice and body weight may be partially mediated by excess energy provided by 100% fruit juice intake. Studies that did not adjust for energy intake showed a significant positive association for body weight gain, whereas studies that did adjust for energy intake found a significant inverse association, suggesting that energy intake may be a mediator in this association. In RCTs in adults, no significant association between 100% fruit juice and body weight was found; however, the CIs were wide, with short study durations and small sample sizes. Although there was no significant subgroup difference between the dose of fruit juice consumed, less than 1 serving per day was associated with a significant reduction in body weight, and greater than 2 servings per day was associated with a significant gain in body weight. This may be due to the greater health benefits conferred from the vitamins, antioxidants, and polyphenols found in some 100% fruit juices at lower doses and risks of harm at higher doses due to the excess energy. Interestingly, although there were no significant differences between the types of juice consumed and body weight, a trend appeared supporting “superfood”–type juices. Pomegranate, berry (goji, barberry, bilberry, and currant), and tart cherry juices tended toward weight loss, whereas apple, citrus, and grape juices tended toward a weight gain. Differences in findings between prospective cohort studies and RCTs in adults may be due to the methodologic differences between the study designs. Individual trials may be limited by short study durations and small sample sizes; however, they are potentially able to assess differences in dose and type of fruit juice. Cohort studies typically evaluate the most commonly consumed juices, likely apple and orange, which may be consumed in greater quantity compared with the superfood juices.

A potential mechanism linking 100% fruit juice to weight gain is the consumption of liquid calories, which has been shown to result in greater weight gain compared with the ingestion of solid calories.^3,4 Compared with whole fruit, 100% fruit juice contains less dietary fiber, leading to the rapid absorption of fructose in the liver. When consumed in excess, this can lead to hepatic de novo lipogenesis, production of very-low-density lipoproteins, and triglycerides.⁷⁴

Strengths and Limitations

Our systematic review and meta-analysis provided comprehensive analyses of children and adults, using data from both prospective cohort studies and RCTs. Inclusion of both study designs is critical to examine the overall evidence, as cohort studies allow us to assess long-term changes in weight, and RCTs can examine causality. We additionally included several separate meta-analyses including assessing cohort studies in a change vs change analysis. This approach efficiently adjusts for within-person non–time-varying confounders. An advantage of this design is the generalizability to a real-world setting, relative to a controlled laboratory setting, because participants are able to change their diet and lifestyle without investigator-driven intervention. We additionally included a separate meta-analysis assessing changes in BMI z score, which is relevant for pediatric populations. Finally, we assessed the certainty of evidence using both GRADE and NutriGRADE.

Our meta-analysis is prone to residual confounding due to the limitations of the included studies with observational designs. Only 5 of 17 cohorts in children and 5 of 6 cohorts in adults used a change vs change analysis. This would be the optimal analysis to assess longitudinal changes in 100% fruit juice intake and concomitant body weight change. Self-reported dietary assessment methods may also be subject to inaccuracies and misreporting errors. This is particularly evident when evaluating juice intake in children, whether through direct reporting or through parents/caregivers as proxies. Substantial heterogeneity was also found in all outcomes and could not be explained by meta-regression analyses. Body weight was not the primary outcome assessed for most of the trials in adults; however, there were no significant differences between groups. RCTs in children have not been conducted, and this represents an area of future research.

Conclusions

Results of this comprehensive systematic review and meta-analysis provide evidence that 100% fruit juice consumption was associated with a small BMI gain in children. Our meta-analysis of prospective cohort studies in adults provides evidence that daily 100% fruit juice consumption was associated with body weight gain, which is likely mediated in part by energy; however, this association was neither supported nor refuted by our meta-analysis of RCTs. There is a need for high-quality RCTs in both children and adults that explore the effect of juice consumption on body weight at different levels of intake and different types of juice. Our findings are in support of public health guidance to limit consumption of 100% fruit juice to prevent overweight and obesity.

Supplement 1.

eMethods. Supplemental Methodology

eTable 1. Search Strategy

eTable 2. Data Transformations and Assumptions

eTable 3. List of Excluded Studies

eTable 4. Characteristics of Included Prospective Cohort Studies in Children

eTable 5. Characteristics of Included Prospective Cohort Studies in Adults

eTable 6. Characteristics of Included RCTs in Adults

eTable 7. Newcastle-Ottawa Scale

eTable 8. GRADE Assessment for Cohort Studies

eTable 9. GRADE Assessment for RCTs

eTable 10. NutriGRADE Assessment for Cohort Studies

eTable 11. NutriGRADE Assessment for RCTs

eFigure 1. Flow of Literature

eFigure 2. Cochrane Risk of Bias Summary

eFigure 3. Cochrane Risk of Bias

eFigure 4. Pooled Effect Estimates for Prospective Cohort Studies in Children Assessing the 1-Year Change in BMI per 1 Serving/Day Increase in Fruit Juice Using a Change vs Change Analysis

eFigure 5. Pooled Effect Estimates for Prospective Cohort Studies in Children Assessing the Change in BMI per 1 Serving/Day Increase in Fruit Juice Using Energy Intake Adjusted Coefficients

eFigure 6. Pooled Effect Estimates for Prospective Cohort Studies in Children Assessing the Change in BMI per 1 Serving/Day Increase in Fruit Juice per a 1-Year Period

eFigure 7. Pooled Effect Estimates for Prospective Cohort Studies in Children Assessing the Change in BMI z Score per 1 Serving/Day Increase in Fruit Juice

eFigure 8. Pooled Effect Estimates for Prospective Cohort Studies in Adults Assessing the 1-Year Change in Body Weight per 1 Serving/Day Increase in Fruit Juice Using a Change vs Change Analysis

eFigure 9. Pooled Effect Estimates for Prospective Cohort Studies in Adults Assessing the Change in Body Weight per 1 Serving/Day Increase in Fruit Juice Using Energy Intake Adjusted Coefficients

eFigure 10. Pooled Effect Estimates for Prospective Cohort Studies in Adults Assessing the Change in Body Weight per 1 Serving/Day Increase in Fruit Juice per a 1-Year Period

eFigure 11. Influence Analysis for Cohort Studies in Children

eFigure 12. Influence Analysis for Cohort Studies Adults

eFigure 13. Influence Analysis for RCTs in Adults

eFigure 14. Subgroup Analysis for Cohort Studies in Children

eFigure 15. Subgroup Analysis for Cohort Studies in Adults

eFigure 16. Subgroup Analysis for RCTs in Adults

eFigure 17. Risk of Bias Subgroup Analysis for RCTs in Adults

eFigure 18. Linear Dose-Response Analysis for Cohort Studies in Children

eFigure 19. Nonlinear Dose-Response Analysis for Cohort Studies in Children

eFigure 20. Linear Dose-Response Analysis for Cohort Studies in Children per a 1-Year Period

eFigure 21. Nonlinear Dose-Response Analysis for Cohort Studies in Children per a 1-Year Period

eFigure 22. Linear Dose-Response Analysis for Cohort Studies in Adults

eFigure 23. Nonlinear Dose-Response Analysis for Cohort Studies in Adults

eFigure 24. Linear Dose-Response Analysis for Cohort Studies in Adults per a 1-Year Period

eFigure 25. Nonlinear Dose-Response Analysis for Cohort Studies in Adults per a 1-Year Period

eFigure 26. Linear Dose-Response Analysis for RCTs in Adults

eFigure 27. Linear and Nonlinear Dose-Response Analysis for RCTs in Adults

eFigure 28. Nonlinear Dose-Response Analysis for RCTs in Adults at a Threshold of 1-Serving per Day

eFigure 29. Publication Bias Contour Enhanced Funnel Plot for Cohort Studies in Children

eFigure 30. Trim and Fill Plot for Cohort Studies in Children

eFigure 31. Publication Bias Contour Enhanced Funnel Plot for Cohort Studies in Adults

eFigure 32. Publication Bias Contour Enhanced Funnel Plot for RCTs in Adults

eReferences

jamapediatr-e236124-s001.pdf^{(3.3MB, pdf)}

Supplement 2.

Data Sharing Statement.

jamapediatr-e236124-s002.pdf^{(15.6KB, pdf)}

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