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Various aspects of lifestyle are associated with the development of obesity, including physical activity, cigarette use (and its cessation), alcohol, television watching, computers, and sleep. Dietary factors are particularly important, both those leading to weight gain, such as starches, meats, fats, and sugar-sweetened beverages, and those contributing to weight maintenance if not loss, including vegetables, whole grains, fruits, nuts, and yoghurt.[1] The important role of sugar consumption in obesity, contributing to diabetes and atherosclerosis, is supported not only by these epidemiologic findings, but also by the concept that this nutrient group particularly increases insulin levels in the setting of Insulin resistance, with hyperinsulinemia potentially further contributing to adverse outcome.[2]

In the October 11 issue of the New England Journal of Medicine, two important studies firmly showed an association between sugar-sweetened beverages (SSB) and the development and worsening of obesity. de Ruyter and coworkers in Amsterdam gave children SSB or a non-caloric-sweetened drink every school day; after 6, 12, and 18 months the latter group had less weight gain. Liquid sugar did not, then, induce satiety. Furthermore, non caloric drinks did not increase hunger, instead reducing the degree of increase in body fat.[3] Ebbeling et al.[4] randomized overweight and obese adolescents to an even simpler intervention, simply offering home delivery of bottled water and “diet” beverages every 2 weeks for a year, with monthly 30-min phone calls to motivate parents and three 20-min check-in visits by the participants. The intervention led to a 15–20% reduction in energy intake with modest weight loss. Interestingly, the control group reported a nearly 10% reduction in energy intake, although not losing weight, suggesting that the increased awareness stemming from participation in the trial may in and of itself constitute a modestly effective intervention. These reports add to prior studies showing that reduction in SSB consumption may be more effective than reduction in calorie intake from solid foods in achieving weight loss.[5] In the Nurses' Health Study of more than 50 000 women followed prospectively from 1991 to 1998, those reducing SSB consumption stabilized weight, while those continuing to drink these beverages had progressive weight gain. Daily SSB consumption doubled the risk of developing diabetes over that among women not consuming these beverages.[6] A similar study among African American women followed from 1995 to 2001 showed a 25 to 30% increase in diabetes risk with daily SSB consumption, with weight gain likely the mediator.[7] A metaanalysis similarly suggested an adverse SSB effect on weight gain and on diabetes risk.[8] Evidence relating SSB consumption to obesity has also been reported in studies in China, among children [9] and among adolescents,[10] a pattern similar to that observed in US studies. Reducing SSB may also lower blood pressure.[11]

Consumption statistics suggest that the use of sugar-sweetened beverages increased in US children age 6-11 from 1990 to 2008. Total beverage calorie consumption was stable, while caloric nutritional beverage, principally high fat low sugar milk, decreased from 210 to 133 Kcal/d, and SSB increased from 130 to 212 Kcal/d.[12] In US studies over the past decade, however, consumption of added sugars overall and of SSB decreased, although still above desirable levels.[13, 14] Production statistics from the Coca-Cola Company and PepsiCo Inc, together responsible for over one third of SSB sold globally, also suggest a reduction in SSB use in the US during this period, although alarmingly showing progressive increase in such beverage consumption in China.[15]

At the end of the nineteenth century, Robert Koch formulated a set of postulates to establish that a given microbe causes disease. Analogously, products of SSB are found in abundance in humans with obesity and its cardiometabolic complications, SSB cause disease when administered in animal models,[16] and replacing SSB with non-caloric beverages prevents the development of these conditions. Paradigms similar to those used in combating the infectious disease epidemics of the past can and should be applied to the epidemic of non-communicable diseases.[17] Here is, then, a simple, proven intervention to reduce the development of obesity and, perhaps, of diabetes, hypertension, and cardiovascular disease. Is it not time to act?

有多种不同的生活方式与肥胖症的发生有关,包括体力活动、吸烟(以及戒烟)、饮酒、看电视、使用计算机以及睡眠。饮食是其中特别重要的因素,有些食物会导致体重增加,如淀粉、肉类、脂肪以及含糖饮料,而有些食物即便不会导致体重下降也有助于维持体重,如蔬菜、全营养谷物、水果、坚果与酸奶[1]。糖类的消耗量在肥胖症、糖尿病与动脉粥样硬化中扮演重要的角色,这一点不仅有流行病学的研究结果可以证实,而且有人认为,在胰岛素抵抗的环境中这组营养素能够显著升高胰岛素的水平,而高胰岛素血症可能会进一步地导致不良预后[2]

在10月11日发行的《新英格兰医学杂志》中,有两项重要的研究结果证实含糖饮料(SSB)与肥胖症的发生以及发展有关。阿姆斯特丹的de Ruyter等在每个上学日都给孩子们提供SSB或者不含热卡的甜饮料,经过6、12以及18个月后发现后一组儿童体重增加较少。含糖液体并不会导致饱腹感。不含热卡的饮料也不会增加饥饿感,相反可以减少体内脂肪增加的程度[3]。Ebbeling等[4]将超重与肥胖的青少年随机分组后对试验组进行一种相对更加简单的干预:在1年的时间里每隔2周仅提供一次送货上门的瓶装水与“无糖”饮料,每个月与父母通话30分钟以提醒,同时每月还要对受试者进行3次访视,每次20分钟。结果显示对试验组的干预导致能量摄入减少了15%–20%,且体重有轻微的下降。有趣的是,对照组能量摄入也减少了近10%,虽然体重没有下降。表明参与这个试验所提高的认识本身就是一种轻度有效的干预。这些报告加上先前的一些研究结果证实,对于减轻体重来说,减少SSB的消费可能比减少固体食物热卡摄入量来得更有效[5]。在护士健康研究中,从1991年至1998年前瞻性地随访了超过50000名的妇女,结果发现那些减少SSB消费的妇女可以维持体重的稳定,而那些继续喝这些饮料的妇女体重在进行性增加。与不消费这些饮料的妇女相比较,每日消费SSB的妇女发生糖尿病的风险增加1倍[6]。从1995年至2001年在非洲裔美国妇女中有一项类似的随访研究,结果发现每日消费SSB可导致糖尿病风险增加25%至30%,这可能与体重增加有关[7]。一项荟萃分析的结果同样表明,SSB对体重增加以及糖尿病风险都有不良的影响[8]。有关SSB消费与肥胖症相关的证据在中国儿童[9]或青少年[10]中也有报告,与那些在美国研究中观察到的结果相类似。此外,减少SSB的消费还可能降低血压[11]

消费统计结果表明,从1990年至2008年,年龄介于6-11岁的美国儿童含糖饮料的消费量有所增加。总的饮料热卡消费量保持不变,而含热卡的营养性饮料,主要是高脂肪低糖牛奶,从210 Kcal/d减少至133 Kcal/d,同时SSB从130 Kcal/d增加至212 Kcal/d[12]。然而,在美国过去十年的研究中,所有的含糖饮料以及SSB的消费量都有所下降,虽然消费量仍在理想水平之上[13, 14]。可口可乐公司与百事公司的产量(加在一起占全球SSB销售量的三分之一以上)统计结果也表明这一时期美国的SSB消费量有所减少,但令人担忧的是这种饮料在中国的消费量却在进行性地增加[15]

在十九世纪末,Robert Koch提出了一系列的假说确定了一种特定的微生物可以导致疾病。与此类似的,发现SSB产品丰富之后与人类的肥胖以及心脏并发症有关,在动物模型中给予SSB后可导致疾病[16],而将SSB替换为不含热卡的饮料后可以预防这些情况的发生。目前应该借鉴过去针对传染性疾病的流行所采取的措施来应对当前非传染性疾病的流行[17]。那么,现在这里有一个简单并且经过证实的干预措施,它可以减少肥胖症的发生,或许还可以减少糖尿病、高血压以及心血管疾病的发生。是不是已经到了我们该采取行动的时候了?

References

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