Statistical analyses performed:  Logistic regression analyses were conducted to predict the odds of low milk and juice consumption by soft drink consumption level. To determine whether intake of select nutrients varied by soft drink consumption, multiple linear regression modeling was conducted. Analyses were conducted using sample weights and software appropriate for the survey design.

Results:  Energy intake was positively associated with consumption of nondiet soft drinks. For example, mean adjusted energy intake was 1,830 kcal/day for school-aged children who were nonconsumers of soft drinks compared with 2,018 kcal/day for children in this age group who consumed an average of 9 oz of soda or more per day. Those in the highest soft drink consumption category consumed less milk and fruit juice compared with those in the lowest consumption category (nonconsumers).


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Conclusions:  Nutrition education messages targeted to children and/or their parents should encourage limited consumption of soft drinks. Policies that limit children's access to soft drinks at day care centers and schools should be promoted.

Therefore, this study intends to explore the association between diet soft drink consumption and MASLD using data obtained from the National Health and Nutrition Examination Surveys (NHANES), and to evaluate the mediating effect of BMI in this association by mediation analysis.

The term soft drink originated to distinguish flavored drinks from hard liquor or distilled spirits and was recommended as a substitute to change the heavy drinking habits of early Americans [7], while the rise of diet soft drinks was related to concerns about obesity. But in recent years, the health problems caused by diet soft drinks have gradually attracted attention. A growing number of studies have shown that diet soft drink consumption is associated with an increased risk of obesity, type 2 diabetes, and other features of metabolic syndrome [10, 14, 15]. The current view is that the health risks of diet soft drinks mainly come from artificial sweeteners, such as aspartame and sucralose. As recently as July 2023, the International Agency for Research on Cancer (IARC) of the World Health Organization (WHO) classified aspartame as possibly carcinogenic to humans (IARC Group 2B). As for the mechanism by which artificial sweeteners increase the risk of MASLD, it should be multifaceted. In addition to BMI as a mediator concerned in this study, previous animal studies have shown that artificial sweeteners can promote insulin resistance [22], and induce glucose intolerance by altering intestinal microbiota [23], both of which are closely related to the pathogenesis of MASLD.

To the best of our knowledge, this is the first study to explore the association between diet soft drink consumption and MASLD in a nationally representative sample, and our findings can provide valuable dietary recommendations for the prevention and treatment of MASLD. Of course, this study also has several limitations. First of all, as a cross-sectional study, the impact of reverse causality cannot be excluded, that is, those participants diagnosed with MASLD may be more inclined to choose diet soft drinks. Secondly, FLI was used for the diagnosis of MASLD in this study, rather than the imaging method commonly used in clinical practice, although FLI has been validated and used in a number of previous studies [24]. Finally, the current study was not able to adjust for genetic variants and sleep patterns, which were also risk factors for MASLD [25, 26], due to the lack of genetic information in the NHANES database and large differences in sleep questionnaire content between the two cycles used in this study. In the future, prospective randomized controlled trials are necessary to provide stronger evidence for our findings.

By analyzing nationally representative data, we found that excessive diet soft drink consumption was associated with the occurrence of MASLD. Additionally, BMI may play a mediating role in the association between diet soft drink consumption and MASLD. Our findings can provide valuable dietary recommendations for the prevention and treatment of MASLD.

This is a time-lapse video on how to make a 3D model from a 2D image, it shows the basic techniques to create a simple 3D model of Soft Drink Can (Coca Cola Beverage Can, 330ml) from reference image of Actual Product in Autodesk Maya.

While soft drink intake is positively associated with weight gain, no previous study has investigated whether leisure-time physical activity modifies this association. We estimated the association between soft drink intake and body weight, and explored if this association differed by levels of leisure-time physical activity.

Soft drink intake was associated with weight gain. Leisure-time physical activity did not modify the association between soft drink intake and weight gain. This finding challenges the idea that leisure-time physical activity is sufficient to counterbalance weight gain associated to soft drink intake.

To test the hypothesis that leisure-time physical activity modifies the association between soft drink intake and body weight over time, we included a three-way interaction term between soft drink, time, and leisure-time physical activity (Model 2). This model also included two-way interaction terms for soft drink and time, soft drink and leisure-time physical activity, leisure-time physical activity and time, sex and time, and age at baseline and time. Model 2 was also adjusted for the time-varying covariates included in model 1. In both models, we used robust standard error estimators to correct for the non-independence of participants that belonged to the same family. To aid with interpretation, we used model 2 coefficients to predict the average marginal weight change per year at pre-specified units of soft drink intake (zero, one, and two servings per day) and by levels of leisure-time physical activity. We do not present predictions for weight change for three or more servings because that group comprised only 3% of the sample. Details about the modeling strategy are included in the Additional File 2. To evaluate the goodness of fit, we used the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC).

Some limitations must be considered. Measurement error from self-reported questionnaires such as the FFQ and physical activity needs to be acknowledged. Soft drink intake measured using an FFQ may differ from usual intake, leading to misclassification bias. Yet, for that misclassification bias to explain these findings, we would need for recall to induce higher reporting in people who gained weight and lower reporting amongst people who did not gain weight. Weight trajectories are heavily influenced by baseline values. Thus, to explore this possibility, we stratified the models by baseline weight. Both, people with and without overweight and obesity, showed similar results (see Table S3 and Table S4, available in Additional file 2). This suggests that these findings are not linked to obesity status at baseline or other variables related to it, such as soft drink recall due to obesity or weight gain. Likewise, levels of physical activity can vary according to BMI categories. However, the distribution of low and high levels of leisure-time physical activity was similar in people with obesity, overweight and normal/underweight weight. Overall, the literature suggests, if anything, that overweight people underestimate their caloric intake, particularly on perceived unhealthy foods and beverages [55,56,57,58]. This would lead to an underestimate of SSB intake among overweight individuals and lead to a larger physical activity effect. This cohort study is relatively small, which could limit the ability to detect statistical significance of the three-way interaction. Yet, the coefficient of the triple interaction was near zero, with both positive and negative effects being equally likely. Thus, it is implausible that increasing the sample size would lead to a clinically relevant effect modification of leisure-time physical activity in the association between soft drink and weight gain. Given the observational nature of this study, we cannot rule out the possibility of residual confounding. Finally, this cohort is not a representative sample of Mexican adults due to different prevalence of chronic diseases with the general population level. Despite these potential limitations, the study has several strengths. We used a prospective study design to analyze a direct path between soft drink intake and weight change. We used objective measurements for weight. We also used an analytical approach that controls for time-invariant confounders, whether they were measured or not. Additionally, the statistical models were controlled by covariates of food groups linked with soft drink intake and weight change. The results were robust for the different sensitivity analyses. Sociodemographic characteristics were similar between the analytic and the full sample, yet, out analytical sample had slightly less women and more participants with secondary and high-school education (see Table S5, available in Additional file 2). Finally, these results can be generalized to other regions where the average soft drink intake is similar to the one of the HWCS population if the modifiers of the association are distributed equally.

In a cohort of Mexican adults, we found that soft drink intake was associated with weight gain. We failed to observe a modifying effect of physical activity over the soft drink intake and weight association; physical activity levels would need to be much higher than observed in this cohort to counterbalance excess energy intake. Public health policies should focus on the regulation of SSB intake at population level, beyond promoting physical activity.

An operating company in Asahi Group responsible for the Non-Alcohol Beverages business in Japan. The company oversees the manufacture and sales of various types of non-alcohol beverages such as carbonated drinks, lactic acid deinks, coffee, ready-to-drink tea. It is also in charge of managing the operation of vending machines, and conducts other related businesses primarily within Japan. 006ab0faaa

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