BACKGROUND Adverse associations of low- and no-calorie sweetened beverages (LNCSB) with cardiometabolic outcomes in observational studies may be explained by reverse causality and residual confounding. PURPOSE To address these limitations we used change analyses of repeated measures of intake and substitution analyses to synthesize the association of LNCSB with cardiometabolic outcomes. DATA SOURCES MEDLINE, Embase, and the Cochrane Library were searched up to 10 June 2021 for prospective cohort studies with ≥1 year of follow-up duration in adults. STUDY SELECTION Outcomes included changes in clinical measures of adiposity, risk of overweight/obesity, metabolic syndrome, type 2 diabetes (T2D), cardiovascular disease, and total mortality. DATA EXTRACTION Two independent reviewers extracted data, assessed study quality, and assessed certainty of evidence using GRADE. Data were pooled with a random-effects model and expressed as mean difference (MD) or risk ratio (RR) and 95% CI. DATA SYNTHESIS A total of 14 cohorts (416,830 participants) met the eligibility criteria. Increase in LNCSB intake was associated with lower weight (5 cohorts, 130,020 participants; MD −0.008 kg/year [95% CI −0.014, −0.002]). Substitution of LNCSB for sugar-sweetened beverages (SSB) was associated with lower weight (three cohorts, 165,579 participants; MD, −0.12 [−0.14, −0.10,] kg/y) and lower incidence of obesity (OB) (one cohort, 15,765 participants; RR 0.88 [95% CI 0.88, 0.89]), coronary heart disease (six cohorts, 233,676 participants; 0.89 [0.81, 0.98]), cardiovascular disease mortality (one cohort, 118,363 participants; 0.95 [0.90, 0.99]), and total mortality (one cohort, 118,363 participants; 0.96 [0.94, 0.98]) with no adverse associations across other outcomes. Substitution of water for SSB showed lower weight (three cohorts, 165,579 participants; MD −0.10 kg/year [−0.13, −0.06]), lower waist circumference (one cohort, 173 participants; −2.71 cm/year [−4.27, −1.15]) and percent body fat (one cohort, 173 participants; −1.51% per year [−2.61, −0.42]), and lower incidence of OB (one cohort, 15,765 participants; RR 0.85 [0.75, 0.97]) and T2D (three cohorts, 281,855 participants; 0.96 [0.94, 0.98]). Substitution of LNCSB for water showed no adverse associations. LIMITATIONS The evidence was low to very low certainty owing to downgrades for imprecision, indirectness, and/or inconsistency. CONCLUSIONS LNCSB were not associated with cardiometabolic harm in analyses that model the exposure as change or substitutions. The available evidence provides some indication that LNCSB in their intended substitution for SSB may be associated with cardiometabolic benefit, comparable with the standard of care, water.

中文翻译：

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低热量和无热量甜味饮料的变化或替代与心脏代谢结果的关系：前瞻性队列研究的系统回顾和荟萃分析


背景观察性研究中低热量和无热量甜味饮料（LNCSB）与心脏代谢结果的不利关联可以通过反向因果关系和残余混杂来解释。目的为了解决这些局限性，我们使用重复摄入测量的变化分析和替代分析来综合 LNCSB 与心脏代谢结果的关联。数据来源 MEDLINE、Embase 和 Cochrane 图书馆检索了截至 2021 年 6 月 10 日的成人随访时间≥1 年的前瞻性队列研究。研究选择结果包括肥胖临床指标的变化、超重/肥胖风险、代谢综合征、2 型糖尿病 (T2D)、心血管疾病和总死亡率。数据提取 两名独立评审员提取数据，评估研究质量，并使用 GRADE 评估证据的确定性。使用随机效应模型汇总数据，并表示为平均差 (MD) 或风险比 (RR) 和 95% CI。数据综合 共有 14 个队列（416,830 名参与者）符合资格标准。 LNCSB 摄入量的增加与体重减轻相关（5 个队列，130,020 名参与者；MD -0.008 kg/年 [95% CI -0.014，-0.002]）。用 LNCSB 替代含糖饮料 (SSB) 与较低的体重（三个队列，165,579 名参与者；MD，-0.12 [-0.14，-0.10，] kg/y）和较低的肥胖 (OB) 发生率相关（一个队列，15,765 名参与者；RR 0.88 [95% CI 0.88, 0.89]），冠心病（6 个队列，233,676 名参与者；0.89 [0.81, 0.98]），心血管疾病死亡率（1 个队列，118,363 名参与者；0.95 [0.90, 0.99] ）和总死亡率（一组，118,363 名参与者；0.96 [0.94，0.98]），与其他结果之间没有不利关联。 以水替代SSB显示出较低的体重（三个队列，165,579名参与者；MD -0.10公斤/年[-0.13，-0.06]），较低的腰围（一个队列，173名参与者；-2.71厘米/年[-4.27，- 1.15]）和体脂百分比（一组，173 名参与者；每年 -1.51% [-2.61，-0.42]），以及较低的 OB 发生率（一组，15,765 名参与者；RR 0.85 [0.75，0.97]）和 T2D （三个队列，281,855 名参与者；0.96 [0.94，0.98]）。用 LNCSB 替代水没有显示出不良关联。局限性 由于不精确、间接和/或不一致而降级，证据的确定性从低到极低。结论 在将暴露建模为变化或替代的分析中，LNCSB 与心脏代谢损害无关。现有证据表明，与标准护理水相比，LNCSB 预期替代 SSB 可能与心脏代谢益处相关。