Abstract
Background: Low-calorie and no-calorie sweeteners (LCSs) have emerged as alternatives to added sugars. Research suggests that consumption among all Americans is increasing, yet it is unknown whether consumption trends differ among population subgroups.
Objective: Our study aimed to assess recent national trends in LCS consumption among children and other demographic subgroups in the United States.
Design: We used NHANES data collected in five 2-y cycles from 1999–2000 to 2007–2008. Consumption of foods and beverages with LCSs was estimated by using one 24-h dietary recall. Estimates of the proportion of the population consuming foods and beverages containing LCSs (prevalence of consumption) were weighted to obtain nationally representative results. Trends in prevalence of LCS consumption and mean intake of beverages sweetened with LCSs were tested by using chi-square tests for trend and F tests.
Results: In 2007–2008, the percentage of children and adults consuming foods and beverages containing LCSs increased. The prevalence of consuming beverages with LCSs increased from 6.1% to 12.5% among children (P-trend < 0.0001) and from 18.7% to 24.1% among adults (P < 0.001). Increases in the prevalence of consumption of calorie-containing beverages with LCSs were observed among all weight, age, socioeconomic, and race-ethnicity subgroups in both children and adults. However, little change in consumption of no-calorie beverages with LCSs or LCS-containing foods was found.
Conclusions: The consumption of LCS-containing beverages has doubled among US children over the past decade. Further research is needed to understand the health effects of this trend.
INTRODUCTION
The prevalence of obesity has increased dramatically in both children and adults (1, 2) and is associated with adverse health conditions, including type 2 diabetes and cardiovascular disease (3). Epidemiologic and experimental evidence demonstrates that intake of added sugars is strongly associated with weight gain and obesity (4). Low- and no-calorie sweeteners offer an alternative to sugars, providing sweetness without significantly contributing to caloric intake (5).
The effects of these sugar alternatives have not been well studied, and both short- and long-term effects have yet to be determined (6). The FDA has approved 5 low- and no-calorie sweeteners for use in the United States. These are collectively referred to as low-calorie sweeteners (LCSs) and include aspartame, acesulfame-potassium, neotame, saccharin, sucralose (7), and the dietary supplement stevia—an extract from the leaves of the Stevia rebaudiana (Bertoni) plant (8). In addition to widespread use in “diet” beverages, LCSs are increasingly being incorporated into foods (9).
Recent human and animal studies (10–12) have shown that LCSs may affect glucose metabolism (11, 13), satiety (14), and vascular function (12), despite their inherent lack of energy. A growing body of evidence suggests that repeated exposure to sweet substances may lead to the development of preferences for highly sweet foods and beverages (15). This is particularly concerning in young children, among whom early exposure to highly sweet substances can lead to the development of dietary patterns replete with highly caloric foods, typically lacking in nutritional value (16).
Mattes and Popkin (9) reported that substantial increases in the consumption of foods with LCSs and marginal increases in the consumption of beverages with LCSs occurred among all Americans between 1989 and 2004. The purpose of this study was to assess recent trends in consumption of food and beverage products containing LCSs in the United States by demographic subgroups over the past decade. We aimed to build on the findings of Mattes and Popkin (9) by evaluating recent trends among demographic subgroups and by stratifying our analyses by LCS source. Because the consumption of sugar-sweetened beverages and other sources of calorie-containing sugars has been declining (17), we hypothesized that consumption of foods and beverages containing LCSs has risen in children and adults and among other demographic subgroups.
SUBJECTS AND METHODS
We used data from NHANES, which is a continuous, cross-sectional study of the US population with data released in 2-y cycles. A description of NHANES sampling methods is provided elsewhere (18). Our sample consisted of persons aged 2 y or older who agreed to participate in one of the 5 NHANES cycles from 1999–2000 to 2007–2008 (n = 47,396). Only those subjects who provided reliable dietary information were included (n = 42,453). Demographic information collected included the participant's age in years (categorized as 2–5, 6–11, 12–17, 18–34, 35–54, or ≥55 y), sex, socioeconomic status (determined by using tertiles of income-to-poverty ratio), and self-reported race-ethnicity (non-Hispanic white, non-Hispanic black, or Hispanic). Those who identified as Mexican American or other Hispanic were combined into one race-ethnicity group entitled “Hispanic.” Participants indicating identification with another race-ethnicity group were included in all analyses, but their estimated trends in LCS consumption are not shown because of the small sample size and heterogeneity within the “other” categorization. All NHANES protocols were approved by the Institutional Review Board at the National Center for Health Statistics. Adult participants and parents or guardians of child participants signed informed consent, and all child participants provided assent before enrollment in the study.
We used data collected from one 24-h dietary recall to estimate the prevalence of consumption of LCSs in the US population (19). Whereas two 24-h dietary recalls have been collected from all NHANES participants since 2003, only one was collected in the earlier years (NHANES 1999–2000 and 2001–2002). To ensure consistency in methods across all time points, we used data from only the first of the 2 recalls to assess dietary intake. Proxy respondents (parents or guardians) were used for survey examinees who were younger than 6 y of age, and children aged 6–11 y underwent assisted interviews (20). The nutrient content of foods and beverages consumed was determined by NHANES by using the Food and Nutrient Database for Dietary Studies, which uses food-composition data from the USDA National Nutrient Database for Standard Reference (21). The Standard Reference provides a product description that indicates whether it contains LCSs. These foods were identified by searching for all food items containing the terms “low-calorie” or “sugar-free.” Because these LCSs are classified as food additives in accordance with Good Manufacturing Practices by the FDA, producers are not required to provide information regarding the quantity of LCSs contained in their products. As a result, no information on the specific type or quantity of LCSs in foods or beverages is available in the USDA database.
A total of 6113 unique food and beverage items were consumed by NHANES participants between 1999 and 2008. Of these food items, 168 contained LCSs, including 81 different beverage items and 87 food items. We used food codes to group foods and beverages that contained LCSs into the following subgroups: reduced-calorie drinks (eg, light fruit juices and diet lemonade), no-calorie drinks (eg, diet soda and sugar-free flavored water beverages), reduced-calorie desserts (eg, sugar-free ice cream and sugar-free pudding), reduced-calorie condiments (eg, reduced-sugar ketchup and sugar-free pancake syrup), and other reduced-calorie foods (eg, light yogurt and no-sugar-added canned peaches). “Low-calorie” was used in this study to represent the use of an LCS, not to suggest that the food or beverage was low in calories. As such, beverages that contained calories and were sweetened with LCSs were referred to as reduced-calorie beverages to distinguish them from beverages sweetened with LCSs that do not contain calories, referred to as no-calorie beverages.
Our key outcome was the trends in the percentage of US children and adults who consumed at least one food and/or one beverage sweetened with an LCS daily (prevalence of consumption). Trends were assessed among all participants aged ≥2 y and among demographic and weight-status subgroups. A “consumer” was defined as an individual who consumed at least one food or beverage item containing an LCS during the 24-h dietary recall period. Among consumers, trends in the mean intake of beverages containing LCSs were assessed.
Statistical analysis software (SAS version 9.3; SAS Institute) was used for all analyses, and specific SAS procedures that allowed for analysis of a complex survey data were used. Sample weights were used to generate nationally representative estimates of the US population ≥2 y. Prevalence of LCS consumption was assessed by using frequency procedures, and subgroup comparisons were made by using Rao's chi-square test. Trends in the mean intake (g) of beverages containing LCSs (among consumers only) were also estimated. Linear trends in intake were tested by using chi-square tests for trends and F tests. All P values were 2-sided, and P < 0.05 was considered statistically significant.
RESULTS
Percentage of population consuming LCSs
The percentage of children consuming foods and beverages containing LCSs nearly doubled from 8.7% in 1999–2000 to 14.9% in 2007–2008 (P-trend < 0.0001; Figure 1), whereas the percentage of the adult population consuming items with an LCS increased by 18%, from 26.9% to 32.0% (P-trend < 0.001). During the same time period, there were no differences in mean caloric intake among children or adults (data not shown).
FIGURE 1.
Mean (±SE) percentage of children (n = 16,716) and adults (n = 26,737) who reported consuming ≥1 food or beverage containing low-calorie sweeteners in each NHANES cycle from 1999–2000 to 2007–2008. Linear trends were calculated by using Wald's chi-square test. Consumers are defined as those who reported consuming ≥1 low-calorie-sweetened food or beverage during the 24-h recall.
Intake of beverages containing LCSs
As shown in Figure 2, the prevalence of consumption of beverages with LCSs has increased dramatically. The increases observed were largely attributable to increased consumption of reduced-calorie beverages rather than no-calorie beverages. Among children, prevalence of reduced-calorie beverage consumption increased from less than 1% to more than 7% (P-trend < 0.0001) (data not shown). Among adults, prevalence of reduced-calorie beverage consumption increased from 2% in 1999–2000 to more than 8% in 2007–2008 (P-trend < 0.0001) (data not shown).
FIGURE 2.
Mean (±SE) percentage of children (n = 16,716) and adults (n = 26,737) who reported consuming food or beverage sources of low-calorie sweeteners in each NHANES cycle from 1999–2000 to 2007–2008. Linear trends were calculated by using Wald's chi-square test. Consumers are defined as those who reported consuming ≥1 food or beverage containing low-calorie sweeteners during the 24-h recall.
Intake of foods containing LCSs
As shown in Figure 2, no difference in the prevalence of consumption of LCS-containing food items was found between 1999–2000 and 2007–2008.
Subgroup analyses
The results presented in Table 1 and Table 2 show the trends in the prevalence of LCS consumption by type and by age, race, weight, income, and sex subgroups. Although the degree of increase in LCS consumption differed across subgroups, increases in the consumption of reduced-calorie beverages, but not of no-calorie beverages or LCS-containing foods, were observed in all subgroups.
TABLE 1.
Linear trends in prevalence of consumption of sources of LCSs from 1999–2000 to 2007–2008 among children and adolescents (2 to 17 y of age) by demographic and weight subgroups1
| Any item with LCS | Reduced-calorie beverage | No-calorie beverage | Condiment with LCS | Dessert with LCS | |
| % | % | % | % | % | |
| Total | |||||
| All children | |||||
| 1999–2000 (n = 3334) | 8.7 ± 0.9 | 1.0 ± 0.3 | 5.3 ± 0.7 | 0.7 ± 0.3 | 0.9 ± 0.2 |
| 2007–2008 (n = 2839) | 15.0 ± 1.2* | 7.4 ± 0.8**** | 6.1 ± 0.9 | 1.7 ± 0.4 | 1.1 ± 0.4 |
| Male | |||||
| 1999–2000 (n = 1700) | 6.8 ± 0.7 | 0.7 ± 0.3 | 3.5 ± 0.5 | 0.6 ± 0.2 | 0.9 ± 0.3 |
| 2007–2008 (n = 1465) | 12.2 ± 1.1 | 6.7 ± 0.9** | 3.7 ± 0.5 | 1.37 ± 0.3 | 1.2 ± 0.3 |
| Female | |||||
| 1999–2000 (n = 1634) | 8.5 ± 0.7 | 1.0 ± 0.2 | 4.8 ± 0.5 | 0.9 ± 0.2 | 0.7 ± 0.1 |
| 2007–2008 (n = 1374) | 13.6 ± 0.8* | 6.7 ± 0.6**** | 4.8 ± 0.5 | 1.7 ± 0.4 | 1.3 ± 0.4 |
| Age | |||||
| 2 to 5 y | |||||
| 1999–2000 (n = 665) | 7.0 ± 0.9 | 0.8 ± 0.4 | 3.3 ± 0.8 | 0.3 ± 0.2 | 1.1 ± 0.4 |
| 2007–2008 (n = 832) | 11.9 ± 2.0 | 6.5 ± 1.1 | 2.9 ± 0.8 | 1.6 ± 0.5 | 1.4 ± 0.6 |
| 6 to 11 y | |||||
| 1999–2000 (n = 961) | 7.0 ± 0.8 | 0.2 ± 0.2 | 4.1 ± 0.6 | 0.2 ± 0.1 | 0.8 ± 0.4 |
| 2007–2008 (n = 1121) | 13.7 ± 0.9* | 6.9 ± 0.8**** | 4.6 ± 0.5 | 1.5 ± 0.3*** | 1.3 ± 0.4 |
| 12 to 17 y | |||||
| 1999–2000 (n = 1708) | 8.3 ± 0.7 | 1.3 ± 0.3 | 4.6 ± 0.5 | 1.2 ± 0.4 | 0.70 ± 0.2 |
| 2007–2008 (n = 886) | 12.9 ± 1.6 | 6.7 ± 1.01 | 5.1 ± 1.2 | 1.5 ± 0.5 | 1.0 ± 0.3 |
| Race | |||||
| White | |||||
| 1999–2000 (n = 730) | 11.9 ± 1.4 | 1.5 ± 0.5 | 7.3 ± 1.0 | 1.1 ± 0.5 | 1.0 ± 0.3 |
| 2007–2008 (n = 902) | 16.4 ± 1.2 | 6.9 ± 0.7** | 7.4 ± 1.0 | 1.9 ± 0.4 | 1.6 ± 0.6 |
| Black | |||||
| 1999–2000 (n = 929) | 5.6 ± 0.9 | 0.6 ± 0.2 | 1.7 ± 0.7 | 0.3 ± 0.2 | 1.0 ± 0.4 |
| 2007–2008 (n = 721) | 11.1 ± 1.3 | 7.8 ± 0.9**** | 1.9 ± 0.7 | 0.7 ± 0.3**** | 1.0 ± 0.4 |
| Hispanic | |||||
| 1999–2000 (n = 1526) | 6.6 ± 0.5 | 0.7 ± 0.2 | 4.1 ± 0.4 | 0.9 ± 0.2 | 0.7 ± 0.2 |
| 2007–2008 (n = 1076) | 11.0 ± 0.0 | 5.2 ± 0.8** | 3.3 ± 0.7 | 2.0 ± 0.3 | 1.1 ± 0.5 |
| Weight status | |||||
| Normal weight | |||||
| 1999–2000 (n = 1811) | 7.0 ± 0.8 | 0.8 ± 0.2 | 3.9 ± 0.5 | 0.7 ± 0.2 | 0.6 ± 0.3 |
| 2007–2008 (n = 1433) | 11.9 ± 1.2* | 6.2 ± 0.6**** | 3.9 ± 0.8 | 1.1 ± 0.3 | 1.0 ± 0.4 |
| Overweight | |||||
| 1999–2000 (n = 469) | 8.1 ± 1.3 | 1.5 ± 0.7 | 3.2 ± 0.7 | 1.1 ± 0.4 | 1.3 ± 0.5 |
| 2007–2008 (n = 373) | 15.6 ± 1.5* | 7.8 ± 1.3 | 5.4 ± 1.0 | 2.4 ± 0.7 | 1.3 ± 0.6 |
| Obese | |||||
| 1999–2000 (n = 592) | 10.3 ± 1.4 | 1.2 ± 0.5 | 6.8 ± 1.1 | 0.8 ± 0.4 | 1.0 ± 0.6 |
| 2007–2008 (n = 531) | 17.0 ± 1.5 | 8.8 ± 1.1 | 6.6 ± 0.9 | 2.0 ± 0.7**** | 1.6 ± 0.5 |
| Income | |||||
| Low | |||||
| 1999–2000 (n = 1869) | 7.0 ± 0.7 | 0.7 ± 0.2 | 3.5 ± 0.5 | 0.7 ± 0.3 | 0.9 ± 0.2 |
| 2007–2008 (n = 1427) | 11.0 ± 0.8 | 6.0 ± 0.6**** | 2.8 ± 0.5 | 1.3 ± 0.3 | 1.3 ± 0.4 |
| Middle | |||||
| 1999–2000 (n = 861) | 6.7 ± 0.9 | 0.8 ± 0.3 | 3.7 ± 0.8 | 0.7 ± 0.2 | 0.6 ± 0.2 |
| 2007–2008 (n = 834) | 14.5 ± 1.6 | 7.0 ± 1.1* | 4.9 ± 0.9 | 1.8 ± 0.4 | 1.6 ± 0.6 |
| High | |||||
| 1999–2000 (n = 574) | 11.2 ± 1.8 | 1.6 ± 0.7 | 7.0 ± 1.20 | 1.1 ± 0.4 | 0.9 ± 0.2 |
| 2007–2008 (n = 577) | 15.3 ± 1.5 | 8.2 ± 1.2* | 6.8 ± 1.07 | 1.7 ± 0.5 | 0.5 ± 0.3 |
All values are means ± SEs. The data were collected from one 24-h dietary recall. Linear trends in prevalence of consumption of each source of low-calorie sweeteners were analyzed by using logistic regression. The prevalence of consumption of LCSs was assessed by using frequency procedures for complex survey design. LCSs include reduced-calorie drinks (eg, light fruit juices and diet lemonade); no-calorie drinks (eg, diet soda and sugar-free flavored water beverages), low-calorie desserts (eg, sugar-free ice cream and sugar-free pudding), low-calorie condiments (eg, reduced-sugar ketchup and sugar-free pancake syrup), and other low-calorie foods (eg, light yogurt and no-sugar-added canned peaches). *P-trend < 0.05, **P-trend < 0.01, ***P-trend <0.001, ****P-trend < 0.0001. LCS, low-calorie sweetener.
TABLE 2.
Linear trends in prevalence of consumption of sources of low-calorie sweeteners from 1999–2000 to 2007–2008 among adults by demographic and weight subgroup1
| Any item with LCS | Reduced-calorie beverage | No-calorie beverage | Condiment with LCS | Dessert with LCS | |
| % | % | % | % | % | |
| Total | |||||
| All adults | |||||
| 1999–2000 (n = 4736) | 26.9 ± 1.0 | 2.1 ± 0.2 | 17.2 ± 1.2 | 10.4 ± 0.8 | 1.4 ± 0.3 |
| 2007–2008 (n = 5690) | 32.0 ± 1.1** | 8.1 ± 0.8**** | 18.6 ± 0.9 | 12.4 ± 0.6 | 2.0 ± 0.3* |
| Male | |||||
| 1999–2000 (n = 2218) | 21.4 ± 0.9 | 1.8 ± 0.3 | 1.7 ± 0.8 | 9.8 ± 0.7 | 1.2 ± 0.3 |
| 2007–2008 (n = 2809) | 25.1 ± 1.3 | 6.0 ± 0.5** | 13.8 ± 0.9 | 10.8 ± 0.9 | 1.9 ± 0.2* |
| Female | |||||
| 1999–2000 (n = 2518) | 25.4 ± 1.0 | 2.1 ± 0.2 | 14.5 ± 0.9 | 11.2 ± 1.0 | 1.6 ± 0.2 |
| 2007–2008 (n = 2881) | 32.9 ± 1.3** | 8.3 ± 0.7**** | 15.6 ± 1.1 | 15.2 ± 0.7* | 1.9 ± 0.3 |
| Age | |||||
| 18 to 34 y | |||||
| 1999–2000 (n = 1635) | 11.0 ± 0.8 | 1.0 ± 0.2 | 7.2 ± 0.6 | 2.6 ± 0.6 | 0.4 ± 0.1 |
| 2007–2008 (n = 1530) | 15.5 ± 1.3 | 5.0 ± 0.8** | 9.2 ± 0.2 | 3.5 ± 0.4 | 0.4 ± 0.2 |
| 35 to 54 y | |||||
| 1999–2000 (n = 1343) | 26.6 ± 1.4 | 1.9 ± 0.3 | 18.2 ± 1.3 | 9.4 ± 0.8 | 0.7 ± 0.2 |
| 2007–2008 (n = 1845) | 28.7 ± 1.6 | 6.4 ± 0.7*** | 17.1 ± 1.5 | 11.8 ± 0.8 | 0.8 ± 0.2 |
| ≥55 y | |||||
| 1999–2000 (n = 1758) | 32.9 ± 1.2 | 2.8 ± 0.4 | 14.9 ± 0.8 | 18.8 ± 1.3 | 3.0 ± 0.2 |
| 2007–2008 (n = 2315) | 38.2 ± 1.1 | 9.2 ± 0.6**** | 16.3 ± 1.0 | 20.3 ± 1.1 | 3.7 ± 0.4*** |
| Race | |||||
| White | |||||
| 1999–2000 (n = 2730) | 31.6 ± 1.1 | 2.6 ± 0.3 | 19.2 ± 1.4 | 13.6 ± 1.1 | 2.0 ± 0.3 |
| 2007–2008 (n = 3539) | 35.7 ± 0.9 | 8.4 ± 0.8**** | 20.1 ± 0.8 | 14.7 ± 1.3 | 2.7 ± 0.2* |
| Black | |||||
| 1999–2000 (n = 1884) | 15.7 ± 1.5 | 2.7 ± 0.6 | 6.2 ± 0.9 | 9.2 ± 1.5 | 0.8 ± 0.2 |
| 2007–2008 (n = 1924) | 22.4 ± 1.4* | 6.9 ± 0.6 | 8.8 ± 1.0* | 10.4 ± 0.7 | 1.3 ± 0.3 |
| Hispanic | |||||
| 1999–2000 (n = 3207) | 18.7 ± 1.6 | 1.0 ± 0.3 | 10.3 ± 0.9 | 7.7 ± 1.0 | 1.3 ± 0.3 |
| 2007–2008 (n = 2701) | 24.5 ± 1.3*** | 5.5 ± 0.5*** | 10.8 ± 1.3 | 13.1 ± 1.0**** | 1.1 ± 0.4 |
| Weight status | |||||
| Normal weight | |||||
| 1999–2000 (n = 2809) | 17.3 ± 1.4 | 1.4 ± 0.3 | 9.2 ± 1.2 | 7.6 ± 1.0 | 1.0 ± 0.2 |
| 2007–2008 (n = 2443) | 21.5 ± 1.3 | 5.5 ± 0.7**** | 10.0 ± 0.9 | 9.3 ± 0.8 | 1.3 ± 0.3 |
| Overweight | |||||
| 1999–2000 (n = 1944) | 25.0 ± 0.8 | 1.8 ± 0.4 | 14.1 ± 0.8 | 11.1 ± 0.8 | 1.8 ± 0.4 |
| 2007–2008 (n = 2160) | 29.5 ± 1.6 | 7.0 ± 0.5** | 14.6 ± 1.4 | 13.1 ± 1.0 | 2.0 ± 0.3 |
| Obese | |||||
| 1999–2000 (n = 1701) | 29.5 ± 1.4 | 2.7 ± 0.4 | 16.8 ± 1.1 | 13.2 ± 1.3 | 1.5 ± 0.3 |
| 2007–2008 (n = 2164) | 35.9 ± 1.4* | 9.0 ± 0.9**** | 19.1 ± 1.0 | 16.6 ± 0.8 | 2.1 ± 0.3*** |
| Income | |||||
| Low | |||||
| 1999–2000 (n = 3942) | 18.7 ± 1.4 | 1.2 ± 0.2 | 9.4 ± 1.0 | 9.1 ± 0.9 | 1.1 ± 0.2 |
| 2007–2008 (n = 3630) | 22.9 ± 1.4 | 5.8 ± 0.5**** | 10.8 ± 1.0 | 10.2 ± 0.7 | 1.7 ± 0.3** |
| Middle | |||||
| 1999–2000(n = 2274) | 23.0 ± 1.4 | 2.2 ± 0.3 | 12.6 ± 0.8 | 10.4 ± 1.1 | 1.5 ± 0.4 |
| 2007–2008 (n = 2610) | 27.6 ± 1.7 | 6.8 ± 0.7** | 12.7 ± 1.2 | 12.1 ± 1.0 | 2.2 ± 0.3** |
| High | |||||
| 1999–2000 (n = 1854) | 32.0 ± 1.4 | 3.0 ± 0.6 | 20.0 ± 1.3 | 13.1 ± 1.4 | 1.9 ± 0.5 |
| 2007–2008 (n = 2289) | 38.3 ± 1.4* | 9.4 ± 1.2*** | 21.8 ± 1.0 | 17.6 ± 1.1 | 1.8 ± 0.3 |
All values are means ± SEs. Data were collected from one 24-h dietary recall. Linear trends in prevalence of consumption of each source of LCSs were analyzed by using logistic regression. The prevalence of consumption of LCSs was assessed by using frequency procedures for complex survey design. LCSs include reduced-calorie drinks (eg, light fruit juices and diet lemonade); no-calorie drinks (eg, diet soda and sugar-free flavored water beverages), low-calorie desserts (eg, sugar-free ice cream and sugar-free pudding), low-calorie condiments (eg, reduced-sugar ketchup and sugar-free pancake syrup), and other low-calorie foods (eg, light yogurt and no-sugar-added canned peaches). *P-trend < 0.05, **P-trend < 0.01, ***P-trend < 0.001, ****P-trend < 0.0001. LCS, low-calorie sweetener.
Sex and age trends
The proportion of consumers of any food or beverage source of LCS increased significantly only among females (girls: P-trend = 0.03; women: P-trend = 0.002). Increases in the prevalence of reduced-calorie beverage consumption were observed among all males (boys: P-trend < 0.01; men: P-trend < 0.01) and females (girls: P-trend < 0.0001; women: P-trend < 0.0001). Stratified by age group, the prevalence of consuming any LCS-containing food or beverage increased only among children aged 6 to <12 y (P-trend <0.05) and was not statistically significant in any adult age group. Dramatic increases in reduced-calorie beverage consumption were observed among all adult age groups but only among children aged 6 to <12 y (P-trend < 0.0001).
Race and socioeconomic trends
Increases in the prevalence of consuming LCSs from any food or beverage source were observed among non-Hispanic black (P-trend = 0.02) and Hispanic (P-trend = 0.0006) adults but not among non-Hispanic white adults. Increases in reduced-calorie beverage consumption, specifically, were observed in Hispanic and non-Hispanic white adults. Although increases in consumption of reduced-calorie beverages were significant in all child racial subgroups, no differences in the prevalence of consuming any LCS-containing food or beverage were found. Increases in consumption of LCSs from any food or beverage source were observed only among the highest-income tertile among adults (P < 0.05), yet the heightened prevalence of reduced-calorie beverage consumption was observed in all income groups in both children and adults.
Weight-related trends
After stratification by weight status, we observed a significant increase in the prevalence of consuming LCSs from any food or beverage source in normal-weight (P-trend < 0.05) and overweight (P-trend = 0.03) children and obese adults (P-trend < 0.05) but not in normal-weight adults. Increases in the prevalence of reduced-calorie beverage consumption were observed in all weight subgroups among adults (P-trend <0.0001) but only among normal-weight children (P-trend < 0.0001).
Mean intake trends among LCS consumers only
The mean intake of LCS beverages (g) among consumers remained stable in the entire cohort but increased among non-Hispanic black (P-trend = 0.03) and middle-income (P-trend = 0.02) children (data not shown). Among adult consumers, mean intake of beverages with LCSs increased significantly only among older adults, ≥55 y of age (P-trend = 0.0004), but not among middle-aged or younger adults (data not shown).
DISCUSSION
The results of our study show that consumption of LCSs has increased substantially since 1999–2000 in both children and adults. Our findings indicate that increased consumption of reduced-calorie beverages, rather than no-calorie beverages or foods containing LCSs, is driving the overall increase in LCS use. Among consumers of beverages with LCSs, the mean intake of LCS-containing beverages has remained stable overall. Building on the findings of Mattes and Popkin (9), our results show that consumption of foods and beverages with LCSs is fairly common: 28% of the total US population report LCS consumption and a much higher prevalence is reported among certain demographic subgroups. Our results also confirm the finding by Mattes and Popkin (9) that consumption of LCS-containing foods is relatively rare in the general population.
The shift toward LCSs could have come as a result of recent obesity-prevention campaigns and the growing popularity of low- and reduced-carbohydrate diets for weight loss over the past decade. The increased prevalence of type 2 diabetes may have also fostered the growing trends in LCS consumption, particularly among older adults in whom diabetes is much more prevalent. It is also possible that the increasing awareness of negative health associations with high added-sugar consumption in recent years may have promoted a switch to beverages (and foods) containing an LCS. Given recent discussions of taxing sugar-sweetened beverages and banning regular sodas in school systems and the growing popularity of differential pricing structures to promote healthier choices, it can be anticipated that LCS consumption will increase further. Most importantly, given the rapid increases in LCS consumption among children, their long-term effects, particularly when started in the early years, need to be studied.
Our data showed age, racial, income, weight, and sex differences in the percentage of the population consuming items containing LCSs. We found that LCS consumption, specifically reduced-calorie beverage consumption, increased the most among females, non-Hispanic black children, and Hispanic adults, although non-Hispanic whites of all ages continued to have the highest prevalence of LCS-containing food and beverage consumption. We also observed dramatic increases in the consumption of LCSs among older adults, obese adults, and adults in the highest tertile of income.
Our study was the first known to evaluate national trends in consumption of LCS-containing foods and beverages among both children and adults and among race-ethnicity, sex, income, and weight-status subgroups. The analysis of a large body of dietary and demographic information, collected over a 10-y period, enabled us to make meaningful subgroup comparisons and to analyze various sources of LCSs in the diet.
Our study had several limitations. Of importance, the lack of information about the type and quantity of LCSs contained in commercial foods and beverages precluded estimation of the absolute amounts of sweeteners consumed. Because we were unable to determine quantities of LCSs, and because each of the 5 NHANES cycles consisted of different participants, we were unable to examine trends in consumption on an individual level. Furthermore, given the self-reported nature of the dietary-recall data used, our results may be subject to recall bias and information bias. For example, some participants may not remember consuming a food or beverage sweetened with an LCS or may not have been aware that the food or beverage that they consumed contained LCSs; hence, our data may have underestimated true consumption levels. Because consumer perceptions of food and beverages containing LCSs have not been studied, social desirability bias may have resulted in either over- or underreporting of true intake and, as such, is expected to have had little overall effect on our estimates.
In summary, the prevalence of consumption of LCSs in the United States has increased substantially since 1999–2000, with consumption predominantly in the form of beverages. The largest observed increases were in reduced-calorie beverage consumption among both children and adults. Our findings emphasize the need for long-term controlled studies to determine the effect of this trend on energy balance and on indicators such as glucose metabolism, which have been shown to be associated with LCS consumption.
Acknowledgments
We thank the participants and staff of NHANES for their contribution to this study.
The authors’ responsibilities were as follows—ACS, JAW, and MBV: designed the research; ACS: analyzed the data; and RJB and MBV: provided advice and consultation. All authors contributed to the writing and revision of the manuscript. None of the authors had a conflict of interest.
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