What is the question?

• The question is: What is the relationship between low- and no-calorie sweetened beverage consumption and growth, body composition, and risk of obesity? The populations of interest for this question include children, adolescents, adults, older adults, and pregnancy and postpartum.

Why was this question asked?

• This systematic review was conducted by the 2025 Dietary Guidelines Advisory Committee as part of the process to develop the Dietary Guidelines for Americans, 2025-2030.

How was this question answered?

• The Committee conducted a systematic review to answer this question with support from the USDA Nutrition Evidence Systematic Review team. This review updated an existing review that was conducted by the 2020 Dietary Guidelines Advisory Committee.

What is the answer to the question?

• Low- and no-calorie sweetened beverage consumption by children and adolescents may not be associated with growth, body composition, and risk of obesity. This conclusion statement is based on evidence graded as limited.
• Low- and no-calorie sweetened beverage consumption by adults and older adults, compared with water or lower amounts of low- and no-calorie sweetened beverages, is not associated with a change in body composition and risk of obesity. This conclusion statement is based on evidence graded as moderate.
• A conclusion statement cannot be drawn about the relationship between low- and no-calorie sweetened beverage consumption during pregnancy and adequacy of gestational weight gain because there is no evidence available.
• A conclusion statement cannot be drawn about the relationship between low- and no-calorie sweetened beverage consumption during postpartum and postpartum weight change because there is not enough evidence available.

How up-to-date is this systematic review?

• Conclusion statements from this review are based on articles published between January 2000 and May 2023.

Background

• This systematic review was conducted by the 2025 Dietary Guidelines Advisory Committee as part of the process to develop the Dietary Guidelines for Americans, 2025-2030. The U.S. Departments of Health and Human Services (HHS) and Agriculture (USDA) appointed the 2025 Dietary Guidelines Advisory Committee (Committee) in January 2023 to review evidence on high priority scientific questions related to diet and health. Their review forms the basis of their independent, science-based advice and recommendations to HHS and USDA, which is considered as the Departments develop the next edition of the Dietary Guidelines. As part of that process, the Committee conducted a systematic review with support from the USDA Nutrition Evidence Systematic Review (NESR) team to answer the following question: What is the relationship between low- and no-calorie sweetened beverage consumption and growth, body composition, and risk of obesity? This review is an update to an existing review that was conducted by the 2020 Dietary Guidelines Advisory Committee.

Methods

• The Committee conducted a systematic review using the methodology of the USDA NESR team. The Committee first developed a protocol. The intervention/exposure was low- and no-calorie sweetened beverage (LNCSB) consumption in children, adolescents, adults, older adults, and pregnancy and postpartum, the comparators were consumption of a different amount of LNCSB (including no consumption and versions diluted with water) and water, and the outcomes were measures of Growth (in children and adolescents) including: height, weight, stunting, failure to thrive, wasting, body circumferences (arm, neck, thigh); Body composition (in children, adolescents, adults, older adults) including: skinfold thickness, fat mass, ectopic fat, fat-free mass or lean mass, waist circumference, waist-to-hip-ratio; Risk of obesity (in children, adolescents, adults, older adults) including: BMI, underweight, normal weight, overweight and/or obesity, and weight loss and maintenance (in adults and older adults); Pregnancy and postpartum-related weight change including: gestational weight gain and postpartum weight change. Additional inclusion criteria were established for the following study characteristics: a) use randomized or non-randomized controlled trial, prospective or retrospective cohort, nested case-control, or Mendelian randomization study designs, b) be published in English in peer-reviewed journals, c) be from countries classified as high or very high on the Human Development Index, and d) enroll participants with a range of health statuses. The review excluded intervention studies less than 12 weeks in duration (in children, adolescents, adults, and older adults).
• NESR librarians conducted a literature search in PubMed, Embase, CINAHL, and Cochrane to identify articles published between January 2000 and May 2023. Two NESR analysts independently screened all electronic results and the reference lists of included articles based on the pre-determined criteria. The results of this search were combined with included articles from the existing review.
• NESR analysts extracted data, from each included article, with a second analyst verifying accuracy of the extraction. Two NESR analysts independently conducted a formal risk of bias assessment, by study design, for each included article, then reconciled any differences in the assessment. The Committee qualitatively synthesized the evidence, from all included articles identified in the updated literature search and from the existing review, according to the synthesis plan, with attention given to the overarching themes or key concepts from the findings, similarities and differences between studies, and factors that may have affected the results. The Committee developed conclusion statements and graded the strength of evidence based on its consistency, precision, risk of bias, directness and generalizability.

Results

Children and adolescents

Conclusion statement and grade

• Low- and no-calorie sweetened beverage consumption by children and adolescents may not be associated with growth, body composition, and risk of obesity. This conclusion statement is based on evidence graded as limited. (Grade: Limited)  

Summary of the evidence

• Seventeen articles met the inclusion criteria for this review, all of which were from observational studies.
• LNCSB consumption was very low in these life stages.
• The direction of results and size of effects were different across studies.
• The size of study groups was small across many studies.
• There were substantial concerns with risk of bias, especially related to confounding and missing data.
• The evidence applies to the U.S. population but may not apply to diverse subgroups based on race and/or ethnicity.

Adults

Conclusion statement and grade

Low- and no-calorie sweetened beverage consumption by adults and older adults, compared with water or lower amounts of low- and no-calorie sweetened beverages, is not associated with a change in body composition and risk of obesity. This conclusion statement is based on evidence graded as moderate. (Grade: Moderate)

Summary of the evidence

• Twenty-seven articles met the inclusion criteria for this review. Eight were randomized controlled trials and 19 were prospective cohort studies. There was only one study conducted exclusively in older adults and most articles had a mean baseline age less than 60 years; therefore, evidence in adults and older adults was synthesized together.
• Results from trials were fairly consistent, with most demonstrating no difference from the control or a lesser effect than a water control on GBCO outcomes. Results from cohort studies lacked consistency in the direction of findings.
• Most of the randomized controlled trials had small sample sizes.
• There were substantial concerns with risk of bias, especially related to confounding and missing data in observational studies.
• The evidence applies to the U.S. population, but may not apply to diverse subgroups based on race and/or ethnicity and socioeconomic position.

Pregnancy

Conclusion statement and grade

• A conclusion statement cannot be drawn about the relationship between low- and no-calorie sweetened beverage consumption during pregnancy and adequacy of gestational weight gain because there is no evidence available. (Grade: Grade Not Assignable)

Summary of the evidence

• No articles met the inclusion criteria for this review and measured low- and no-calorie sweetened beverage consumption during pregnancy.
• The 2025 Committee was not able to draw a conclusion because there was no evidence available.

Postpartum

Conclusion statement and grade

• A conclusion statement cannot be drawn about the relationship between low- and no-calorie sweetened beverage consumption during postpartum and postpartum weight change because there is not enough evidence available. (Grade: Grade Not Assignable)

Summary of the evidence

• One article from a prospective cohort study met the inclusion criteria for this review and measured low- and no-calorie sweetened beverage consumption during postpartum.
• The 2025 Committee was not able to draw a conclusion because there was not enough evidence available.

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Suggested citation: Raynor HA, Deierlein AL, Gardner CD, Giovannucci E, Taylor CA, Hoelscher DM, Anderson CAM, Booth SL, Fung TT, Stanford FC, Talegawkar SA, Tobias DK, Webster A, Kingshipp B, Cole NC, Higgins M, Butera G, Terry N, Obbagy J. Low- and No-Calorie Sweetened Beverages and Growth, Body Composition, and Risk of Obesity: A Systematic Review. November 2024. U.S. Department of Agriculture, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Nutrition Evidence Systematic Review. Available at: https://doi.org/10.52570/NESR.DGAC2025.SR04