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Nutritively sweetened beverages (NSBs) may play a role in the obesity epidemic. We abstracted data from randomized controlled trials (RCTs) and evidence-based reviews through January 2009 concerning effects of consumption of NSBs on changes in body weight and adiposity. Studies included were those 1) conducted in humans; 2) lasting at least 3 weeks; 3) incorporating random assignment of subjects to conditions that differed only in the consumption of NSBs; and 4) including an adiposity indicator as an outcome. Twelve studies met the inclusion criteria. Meta-analysis of 6 studies that added NSBs to persons' diets showed dose-dependent increases in weight. Contrarily, meta-analysis of studies that attempted to reduce NSB consumption consistently showed no effect on BMI when all subjects were considered. Meta-analysis of studies providing access to results separately for subjects overweight at baseline showed a significant effect of a roughly 0.35 standard deviations lesser BMI change (i.e., more weight loss or less weight gain) relative to controls. The current evidence does not demonstrate conclusively that NSB consumption has uniquely contributed to obesity or that reducing NSB consumption will reduce BMI levels in general. We recommend an adequately powered RCT among overweight persons, among whom there is suggestive evidence of an effect.
Two propositions are widely expressed: (a) the consumption of nutritively sweetened beverages (NSBs) contributes significantly to the development and maintenance of overweight and obesity, and (b) reducing the consumption of NSBs will lead to weight loss or less weight gain (1). These propositions are plausible because epidemiologic studies support an association between NSB consumption and obesity (2). animal studies have shown that ad libitum consumption of NSBs leads to increased body weight (3, 4), and short-term studies of food intake regulation have suggested that consumption of energy-yielding beverages may be poorly compensated (5). Yet, at the same time, there are epidemiologic studies (6-9), animal studies (10-13), and short-term physiologic or behavioral studies (14, 15) that do not show such associations or effects. Recently published critical reviews and formal meta-analyses on the role of NSBs in overweight and obesity have yielded discrepant findings (16-20). One meta-analysis concluded, "We found clear associations of soft drink intake with increased energy intake and body weight" (17), whereas another stated, "The quantitative meta-analysis and qualitative review found that the association between SB [NSB] consumption and BMI [body mass index; kg/m2] was near zero, based on the current body of scientific evidence" (18).
How do we move forward from this quandary? As proposed in a recent commentary (1), there are different paths for different purposes. For those engaged in clinical practice or setting public health policy, overweight and obesity are immediate problems demanding action, and decisions must be made based on the totality of the available evidence. Faced with imperfect knowledge, both fields rely on professional judgment guided by evaluation of potential risks and benefits. Much to the frustration of consumers, recommendations have changed, as they should, when new knowledge provides insights relevant to the association between NSB consumption and weight management or the risks associated with varying levels of intake. The challenge to researchers is to provide the substrate upon which clinical and public health decisions are made, namely sound scientific evidence, and to do so as objectively, thoroughly, and efficiently as possible. It is to this purpose that we undertook the present critical review of the published randomized controlled trials (RCTs). We focus on RCTs because they are the only studies that can control for both known and unknown confounders and are an especially persuasive force to resolve controversy about the effects of interventions. As the US National Institute of Diabetes and Digestive and Kidney Diseases (21) stated, "Well conducted clinical trials are the fastest and safest way to find improved [obesity] treatments and preventions…".
Assessment of the experimental literature that had been included in prior evidence-based reviews indicated that the experimental studies previously evaluated did not target a common hypothesis, address a common research question, or estimate a common parameter. As such, we question whether there was ever justification for jointly meta-analyzing these experimental studies en masse as they were meta-analyzed. We recognize that concerns about heterogeneity are omnipresent in meta-analyses and do not mean to imply that meta-analyses cannot appropriately model heterogeneity, such as diverse subject populations, study designs, outcome measurement procedures, etc. However, this is quite different from meta-analyzing studies that address fundamentally different questions. Although it is mathematically possible to average estimates of completely different parameters, it is not clear that it is meaningful to do so nor what the final average estimate would represent. Herein, we meta-analyze two sets of studies separately that we believe address a common hypothesis within each set.
To identify which hypotheses or research questions could be addressed, and to further clarify which articles should be included, we evaluated both the previously reviewed experimental literature and several additional relevant studies. Table 1 (22-36) lists the questions or hypotheses that could potentially be addressed by each study and the rationale for excluding some studies from the present review.
Studies were first identified through other recent evidence-based reviews that examined the broader literature of NSBs and obesity (16-18, 37-42). We supplemented this with thorough searches of PubMed, PsycINFO, the Cochrane Collaborative Website, Web of Science, and Dissertation Abstracts to identify additional sources, including recent and unpublished sources that may not have been included in the earlier reviews. Databases were searched through January 2009. No sources were excluded on the basis of language. Search terms included "sugar sweetened beverage," "soda," "liquid calories," and "chocolate milk," among others. Example search terms used in PubMed: "BMI" OR "body mass index" OR obes* OR overweight OR "weight gain" OR adipos* OR "body fat" AND beverag* OR "soft drink" OR "soft drinks" OR soda OR liquid. Our inclusion criteria for studies were as follows:
See Figure 1 for a flow chart of the studies screened and selected for final analysis.
The outcome measures we considered were any indices of or proxies for adiposity, including weight, BMI, percent body fat, or dichotomous indicators of overweight or obesity. Although other outcomes such as reported hunger or energy compensation in preload studies are informative, they do not offer direct evidence related to the effects of NSBs on adiposity.
Initially, we considered conducting a formal meta-analysis on the totality of the studies meeting our inclusion criteria. However, review of the studies listed in Table 1 indicated that doing so was not justified. From our perspective, the questions addressed by the different studies were so disparate that there was no common parameter being estimated. We did calculate an effect size for each study to characterize the magnitude of effect, and we provide an indication of its statistical significance. Because the outcome measures used (e.g., change in BMI versus change in BMI z-score, log versus non-log transformed) varied and were not comparable across studies, we used the standardized mean difference (43) as an effect size indicator. Our analysis provides this descriptive and inferential statistical information for each study; a narrative and tabular review of the studies' designs, results, limitations, and justifiable conclusions; and for 2 subsets of studies that addressed sufficiently common questions, we performed a formal meta-analyses. Forest plots were generated with Review Manager, version 5 software (44).
To assess study level risk of bias, two authors independently reviewed the included studies using the guidelines contained in the Cochrane Handbook for Systematic Reviews of Interventions (45). Disagreements in ratings were discussed until consensus was reached. Risk of bias detail and summary figures were generated with Review Manager, version 5 software (44).
See Figure 1 for a flow chart of the screening and selection of studies. The relevant data from all experimental studies included in previous reviews and the additional studies we identified are summarized in Table 1. For reasons explained below, we have excluded three of the studies listed in Table 1 that previous reviews have, in our opinion, erroneously considered to be experimental assessments of the effects of NSBs on weight or adiposity. This left us with a total of 12 studies (Table 2), which includes one study that assessed the effects of liquid versus solid energy consumption (23), 4 studies that assessed the effects of adding mandatory NSB consumption to persons' diets (22, 29, 30, 33), 6 studies that assessed the effectiveness (as opposed to efficacy) (43) of applied programs aimed at decreasing NSB consumption (26, 28, 31, 32, 35, 36), and 1 study that assessed the relative effectiveness of a weight-reducing, energy-restricted diet that disallowed consumption of NSBs and a comparable diet that allowed consumption of up to 12 oz (355 mL) of NSB per day (34).
Three studies (24, 25, 27) included in prior evidence-based reviews of soft-drink or NSB consumption and obesity [i.e., the reviews conducted by Malik, et al. (16), Vartanian, et al. (17), Olsen and Heitmann (20), and Pereira (46)] are not included here. Our rationale for excluding them follows.
The study by Grandjean, et al. (24) consisted of essentially 1-d treatment periods in which variations in weight were used as proxies for, and most likely reflected, hydration status rather than information on the effects of the habitual consumption of NSBs on adiposity. Moreover, were this study included, then previous reviews (17) containing the Grandjean, et al. article also should have included other studies assessing hydration [e.g., a study by Saat, et al. (47)].
In the study by Raben, et al. (25), the independent variable to which the subjects were randomly assigned was not one that permitted inferences about NSB consumption, but rather about sweeteners. Specifically, Raben, et al. addressed the question, "What is the effect of required ingestion of no less than a specified amount of both solid and liquid items containing sucrose versus required ingestion of both solid and liquid items containing non-caloric sweeteners?" This was not a test of nutritive sweetener-containing solid food versus beverage or of NSB consumption versus non-NSB consumption, because the sweeteners were presented in both solid and beverage food forms. Hence, Raben, et al. wrote, "In conclusion, predominantly female overweight subjects who were given supplemental drinks and foods containing sucrose for 10 wk experienced increases in …body weight…. This was not observed in a similar group of subjects given similar drinks and foods containing artificial sweeteners" (25). The authors venture that this was most likely due to "the use of large amounts of beverages, giving rise to overconsumption of energy on the high-sucrose diet." This is a plausible claim, but not one able to be substantiated from the data because the study was designed to test the broader question noted above.
Finally, Van Wymelbeke, et al. (27) used a complex design intended to assess flavor-energy associative learning. Participants received energy-yielding beverages and non-energy-yielding beverages alternating on a daily basis. Again, this is a useful study, but it was not designed to allow (nor was it intended to allow) definitive claims founded on a valid comparison of weight changes between NSB and non-NSB conditions. Hence, we excluded these 3 studies because they were not experiments of the effects of NSBs on weight or obesity.
We identified only one study that permitted a direct comparison of the consumption of an NSB with that of an energy-matched solid carbohydrate food form (23). That trial provided 1880 kJ/d of commercial sodas or jelly beans to 15 adults (mean BMI = 21.9 ± 2.2 kg/m2) and monitored energy intake and body weight change over 4 wk in a randomized crossover design. Precise dietary compensation was noted with the jelly beans (118%), and little was observed with the soda (−17%). Body weight and BMI increased significantly after ingestion of the soda, but not with the jelly beans.
Although the findings are indicative of an NSB-specific effect, such a conclusion must be drawn cautiously. The changes in weight and BMI did not differ significantly between the 2 interventions, and several methodological issues may be relevant. First, there was no control for energy source, so it cannot be concluded that carbohydrate has any unique effect. Indeed, other work challenges this view (5, 48). Second, there was no attempt to control when or how the loads were ingested, and 82% of the time the jelly beans were consumed as "snacks," whereas this held for only 49% of the use of the sodas. Thus, it is unclear if or how these patterns of use affected the outcome. Some evidence suggests it could have augmented the differential response (49, 50).
Finally, this was more of an efficacy than an effectiveness trial (i.e., daily consumption of the loads was required), so extrapolation to free-living conditions, where intake may be more moderate and intermittent, is uncertain. These limitations notwithstanding, this lone trial contrasting food forms does implicate NSBs in weight gain.
Four studies assessed the effects of adding mandatory NSB consumption to persons' diets (Table 3) (22, 29, 30, 33). The added daily energy loads ranged from ~180 kcal to 530 kcal (~754 kJ to 2219 kJ). The time periods ranged from 3 wk to 1 y. Sample sizes ranged from less than 30 to133. For 5 of 5 estimates from the 4 studies (separate estimates for males and females were available in 1 study), the results were in the direction of mandatory NSB consumption leading to greater weight gain than control conditions. However, the results were statistically significant in only 2 studies (22, 33).
The 2-tailed probability of obtaining 5 out of 5 independent results in the same direction if there is no effect in any of the populations sampled is 0.0625, which is marginally significant. The nature of these 'efficacy' studies, where dose is essentially well-controlled (unlike the effectiveness of NSB reduction trials reviewed below), lends well to a meta-analytic approach based on dose response. In Figure 2, we plot the 5 estimates of effect against the daily required energy of NSB consumption. All studies reported the outcome in absolute weight gain, permitting use of weight gain in kg as an outcome (effect size) metric. Hence weight gain was regressed on NSB dose expressed in kcal in a weighted least squares (WLS) regression with each study's weight equal to the inverse of the variance of the estimated effect size. We did not force the regression through the origin as some investigators choose to do in similar nutritional intervention meta-analyses (51), even though a zero change in intake should produce a zero change in outcome. This is because the dose-response relation need not be linear over the entire theoretical range even if it appears approximately linear over the observed range. In such cases, forcing a linear regression through the origin can radically bias the resulting coefficients and also create other well-established interpretive difficulties (52, 53).
The meta-regression revealed a dose-response relation (Pearson's r, with observations weighted by the inverse of their variances = 0.92, P = 0.029) with a slope of .0022 (SE = .00057) and an intercept of −0.357 (SE = .249). Thus, for example, if this adequately represents a causal effect, a 250 kcal daily mandatory consumption load (roughly equivalent to a 20-oz bottle of non-diet soda) would be expected to increase weight roughly 0.2 kg (0.44 lbs) over a 3-to 12-week period. See Figure 3 for a forest plot of the standardized effects for added NSB consumption. Figure 3 should be interpreted with caution, as this representation averages effects over all doses. See Figure 2 for the dose-response relationship of mandatory NSB consumption to weight. Two points are noteworthy here. First, given the possibility of confounding factors across studies, meta-regression dose-response relations may not represent causation and, therefore, should be viewed with caution (54). Second, as noted elsewhere (55), it would be inappropriate to project this forward beyond 12 wk in time by linearly increasing the weight gain per unit time because of compensatory changes in energy expenditure that result from increased body mass.
Our interpretation of these studies is that they suggest an effect of mandatory NSB consumption on increasing weight relative to certain controls. However, sample sizes were small and the study durations short, precluding confident inferences. Moreover, it is not clear to what degree these results are dependent on the control condition being either restricted to no NSB consumption or required consumption of non-NSBs. This is an important point from the perspective of clinical and public health recommendations and needs to be explored further.
Six reports provided information on the effects on adiposity of programs aimed at decreasing consumption of NSBs (26, 28, 31, 32, 35, 36). One of these reports was a longer-term follow-up of the same subjects studied in 2004 (32). These studies ranged in duration from 4 wk to 52 wk with a follow-up at 3 y from baseline. Sample sizes ranged from 103 to 1140.
The first such study was the cluster-randomized RCT of James, et al. (2004) (26). These authors studied children aged 7 to 11 y in 6 junior schools in the United Kingdom. The outcome measures were anthropometric measurements. The first author (James) delivered the intervention to all classes. According to the authors, the main objective "was to discourage the consumption of 'fizzy' drinks (sweetened and unsweetened) with positive affirmation of a balanced healthy diet. [Children]… were told that by decreasing sugar consumption they would improve overall wellbeing and that by reducing the consumption of diet carbonated drinks they would benefit dental health." Children in the treatment group were provided four psycho-educational sessions during the course of the school year; "teachers were encouraged to reiterate the message in lessons," and "children were also encouraged to access further information through the project's website." There is no statement that the control group received comparable attention or non-treatment intervention.
At 12 mo, while consumption of carbonated drinks decreased in the intervention group compared with the control group (mean difference 0.7, 0.1 to 1.3 glasses/d), there was no significant difference in BMI change by treatment assignment. There was, however, a significant difference in change in the proportion of children who exceeded a cut-off used to define overweight or obesity. Specifically, the percentage of overweight and obese children increased in the control clusters by 7.5%, compared with a decrease in the intervention group of 0.2% (mean difference 7.7%, 2.2% to 13.1%). Three years after baseline and two years after the active intervention [James, et al., 2007; (32)], mean BMI had increased in both the intervention and control groups, and the difference in change in BMI between the groups was not statistically significant (1.88 ± 1.71 and 2.14 ± 1.64 kg/m2, respectively, P = 0.12). In addition, the prevalence of overweight increased in both groups at 3 y, and the significant difference in this measure between the groups seen at 12 mo was no longer evident.
An apparent shortcoming of these studies was the lack of an attention placebo in the control group. Control group subjects did not receive educational sessions nor were they offered access to the project website. Thus, it is not clear whether the effects observed were due to reduction in NSB consumption or other nonspecific factors and intervention components that were allowed to be perfectly confounded with treatment assignment. Yet an additional concern is the lack of indication as to whether the dichotomous analysis that showed some efficacy (while the analysis of BMI as a continuous variable did not) was pre-planned or post-hoc (56). We were unable to ascertain whether this was specified a priori in the protocol.
For 25 wk, Ebbeling, et al. studied 103 ostensibly healthy, non-dieting, non-smoking adolescents who reported consuming at least 360 mL/d of NSBs and had BMIs above the population 25th percentile (28). Subjects were individually randomly assigned to intervention or control conditions, and all subjects were available for endpoint measurements. The intervention group received weekly home deliveries of self-selected, non-energy-yielding beverages throughout the study and were told to drink the beverages provided and not to buy or drink NSBs. Additional non-energy-yielding beverages also were provided for family members to avoid competition between the subjects and family members for the beverages. Intervention subjects also received advice on how to choose non-energy-yielding beverages when not at home, written instructions regarding beverage consumption, monthly mailed refrigerator magnets with informational and motivational slogans, and monthly phone calls from study staff to provide "motivational counseling." Control group subjects were asked only to continue their usual beverage consumption habits.
The change in BMI, adjusted for sex and age, was 0.07 ± 0.14 kg/m2 (mean ± SE) in intervention subjects compared with 0.21 ± 0.15 kg/m2 in control subjects. The net difference in change in BMI between the groups (−0.14 ± 0.21 kg/m2) was not statistically significant. Baseline BMI was a significant effect modifier; the intervention effect was significant in subjects with a baseline BMI >30 kg/m2. Among subjects above the upper tertile of BMI at baseline (BMI ≥25.6 kg/m2), the change in BMI between the 2 groups differed markedly: −0.63 ± 0.23 kg/m2 in the intervention group and +0.12 ± 0.26 kg/m2 in the control group (P = 0.03).
A shortcoming of this study was the lack of an attention placebo in the control group. Control group subjects were asked only to continue their usual beverage consumption habits throughout the 25-week intervention period. They received no written instructions, telephone calls, or refrigerator magnets. Thus, it is not clear whether effects (or lack thereof) observed were due to reduction in NSB consumption or other nonspecific factors and intervention components that were allowed to be perfectly confounded with treatment assignment. Additionally, the authors used a stratified randomization procedure, but it does not appear that they took the stratification into account in the subsequent statistical modeling, as would be standard practice (57). Moreover, although Ebbeling, et al. indicate their subgroup analysis was pre-planned (58), it is curious that they stratified on one BMI threshold, yet used a different BMI threshold in their analysis of high-BMI children only. The subgroup analysis showed a significant effect, whereas the analysis of BMI in the entire sample showed no effect of treatment assignment. A replication and extension study is currently underway (see http://clinicaltrials.gov/ct2/show/NCT00381160?term=beverages&rank=1).
This doctoral dissertation reports on the effectiveness of a brief intervention to reduce soda consumption in a college population (31). A total of 303 university undergraduate students (who received course credit for participating) were included. The only inclusion criterion was current consumption of non-diet sodas. Subjects were randomly assigned to 1 of 3 groups: 1) a group that received information on the health risks associated with soda consumption (including type 2 diabetes mellitus, calcium deficiency, and dental ailments; n = 111), 2) a group that received information on the obesity risks associated with soda consumption (n = 95), or 3) a control group that received no information (n = 97). Weight and height were measured at baseline, after which the intervention subjects received their respective intervention handouts. These included research-based information on how to reduce soda consumption for improved health and weight, along with a 5-question short-answer quiz at the end to help ensure that the handouts were read by the subjects. No further intervention activities occurred. A single follow-up visit occurred 1 month after the baseline visit.
Soda consumption decreased significantly in all groups over the 1-month study period, with a nearly equal mean reduction of approximately 16 oz/d (355 mL/d) in both intervention and control groups. BMI increased in all 3 groups between baseline and the follow-up visit, with soda consumption showing no association with BMI at the follow-up visit in any group.
Given the null findings of this study, it is important to consider those factors that may have contributed to, or at least led to failure to control for, extraneous variance in the data and thereby reduced power and precision. Inclusion criteria were poorly defined, with the only stated criterion being current consumption of non-diet sodas, of which a minimum amount was not specified. Potential subjects apparently were not screened for health problems, current weight-loss diets, or other factors that may have affected weight change. It is not apparent that the randomization took baseline BMI into account. There was no attention placebo in the control group, nor did control subjects receive study handouts. Both interventions were minimal (consisting only of 1-page handouts delivered on one occasion), and the intervention period was short.
This school-based cluster randomized trial conducted in Niteroi, Rio de Janeiro, Brazil evaluated whether an educational program aimed at discouraging students from drinking NSBs could prevent excessive weight gain. Forty seven classes in 22 schools were randomized as intervention or control. Participants were 1140 fourth graders (age 9 to 12 y), including 526 in the intervention group and 608 in the control group (6 randomly assigned subjects did not have baseline measures). The intervention consisted of a healthy lifestyle education program, including simple messages regarding the importance of drinking water and encouraging water consumption instead of NSBs. The main strategies were to convey the messages that drinking water is positive and that water should take precedence over NSBs. Education was delivered via classroom activities (10, one-hour sessions of activities facilitated by trained research assistants), musical activities (three, 1-hour sessions), and printed materials given to intervention subjects. In addition, banners were hung promoting water consumption, and water bottles with the logo of the campaign were given to children and teachers at the intervention schools. The control group received only two, 1-hour general sessions on health issues and printed general advice regarding healthy diets. The main outcome was change in BMI measured at the beginning and at the end of the school year.
Mean follow-up time was approximately 8 mo in both groups, with 82.5% of intervention and 81.1% of control students having repeat measurements at follow-up. At the conclusion of the study (end of the school year), there was a reduction of 69 ml in the intervention group and of 13 ml in the control group (P < 0.05), accounting for about a 100-kJ/d difference. However, BMI increased slightly in both groups (by 0.32 kg/m2 in the intervention group and 0.22 kg/m2 in the control group; NS). In a subgroup analysis, girls who were overweight at baseline showed a statistically significant reduction in BMI. Overall, the prevalence of obesity changed from about 4% to 4.5% in both groups. A shortcoming of this trial was the lack of an appropriate attention placebo. Subjects in the control group received 2 hours of general health information, compared to 10 hours (plus 3 hours of musical activities) in the intervention group.
This 16-week RCT examined the effects on body composition of delivering milk beverages to the homes of overweight and obese children to displace NSBs. In this study, 98 children aged 8-10 y, who regularly consumed NSBs, were randomly assigned to an intervention or control group. Children in the intervention group were visited by a nutritionist in their homes weekly to deliver milk beverages, provide instructions to the family about consuming the delivered beverages, and encourage parents to remove NSBs from their homes. Children were counseled to drink 3 portions per day of the milk beverages. Intervention children were encouraged to take the milk beverages to school for consumption during lunch and instructed not to consume NSBs. Milk beverages also were supplied to siblings of intervention subjects, and household members were encouraged to support the subjects by not drinking NSBs. No instructions were given to subjects regarding food or beverage choices in the control group, nor was there any contact with them, other than to conduct assessments.
Milk consumption increased by approximately 450 g/d for the intervention group (P < 0.0001) and did not change for the control group. Consumption of NSBs decreased in the intervention group by 96% (P < 0.0001) and increased in the control group by 9% (P = 0.04). However, changes in percentage body fat (increase of 0.36% in the intervention group and increase of 0.78% in the control group) and BMI (increase of 0.08 kg/m2 in the intervention group and decrease of 0.09 kg/m2 in the control group) were small and did not differ significantly between the groups, although accretion of lean mass was slightly greater in the intervention group than in the control group (P = 0.04).
As in many of the studies reviewed above, an apparent shortcoming of this study was the lack of an attention placebo in the control group. Control subjects did not receive visits from study personnel and, in fact, were not contacted at all except to conduct assessments. That being said, given the null findings, this is not a major concern. In addition, a proper intent-to-treat analysis was not conducted. One might argue that the Albala trial is not relevant to questions of NSB consumption on weight under the supposition that if one replaces NSB consumption with another energy-yielding beverage, energy balance and therefore body weight may not be affected. This supposition may or may not be correct. Nevertheless, this study is informative about the effects of encouraging children to consume milk in place of NSBs.
In summary, the primary question addressed in these trials was whether an educational intervention could affect a reduction in NSB consumption. Changes in indices of adiposity were secondary outcomes in most of these studies. The lack of comparable intervention activity in the control groups and the short duration of some trials hampers interpretation of the primary endpoints, let alone the secondary outcomes. The finding of a greater effect size among overweight subjects in one study (28) and overweight girls in another study (35), who may be at increased risk of health complications, is noteworthy and is addressed more thoroughly in the meta-analyses below.
Table 4 contains a summary quantifying the effect size for all NSB reduction effectiveness studies and Table 5 provides the results of our meta-analysis. As an outcome variable, we chose change in BMI because it was commonly reported across all studies. In studies of children that reported age-adjusted z-scores of BMI, we used those. For our primary analysis, we analyzed all studies except that of James, et al. (2007) (32) because that was not independent of the James, et al. (2004) (26) study and was different from others in that it was a study of a long-term post-intervention follow-up. We used the standardized mean difference (also known as Cohen's d) as an effect size metric to allow us to integrate studies that used raw BMI units and also z-scores of BMI. We scaled the effect size such that positive numbers meant the study favored the treatment group (i.e., that those on treatment had smaller increases in BMI or reduced BMI more than those in the control group). See Figures Figures44 - -55 for forest plots of the sub-group comparisons of standardized effects for reduced NSB consumption.
We conducted a fixed effects meta-analysis as described by Hedges and Olkin (59) with heterogeneity statistics calculated as described elsewhere (60). As can be seen in Table 5, the overall estimate of standardized mean difference in BMI was extremely close to zero (−0.037; SE = 0.042; P = 0.378). The confidence interval was −0.120 to 0.046, indicating the non-significance of the overall effect estimate. The Q or χ2 test of heterogeneity was not significant (P = 0.643) and the I2 statistic, an indicator of the magnitude of among-study heterogeneity in outcome, was 0.00%. These results indicate that there was no statistically significant effect overall; that if they produce an effect at all, it is unlikely that interventions of the types studied to date could produce more than 0.05 of a standard deviation unit lesser BMI change (the upper limit of the 95% CI) in treated versus untreated subjects on average, and that the results appear consistent from study to study.
As a sensitivity analysis, we also repeated the meta-analysis 4 different ways. First, we added the James, et al. (2007) (32) study, despite the fact that it was not independent of the James, et al. (2004) (26) study. Second, we eliminated the study by Munoz (31) because it was an outlier in terms of the minimal nature of the intervention and its brevity. Third, we re-ran the analysis eliminating both the James, et al. (2007) (32) and Munoz (2006) (31) studies. Finally, we reran the analysis eliminating the Albala, et al. (36) study because, as described above, one might argue that the Albala trial is not relevant to questions of NSB consumption on weight under the supposition that if one replaces NSB consumption with another energy-yielding beverage, energy balance and therefore body weight may not be affected. The results of these sensitivity analyses were not appreciably different than that of the primary analysis (see Table 5), lending confidence to the conclusions.
Notably, this meta-analysis assesses the effects of programs aimed at NSB reduction as the primary outcome on a secondary outcome measure, obesity. They were not trials of the effects of NSB reduction per se on obesity. Actual reductions of NSB consumption varied markedly. At least 2 trials (31, 35) achieved only a very minimal change of NSB consumption, so lack of effect on BMI was predictable, and another (36) aimed to substitute milk for NSB rather than just moderate NSB consumption. Thus, the latter might not have been expected to effect a change of weight. The strongest trial methodologically (28) had the largest effect size, although even this was not significant in the study's total sample.
We next conducted a subgroup meta-analysis. Because, as mentioned above, Ebbeling, et al. (28) had reported significant results in those subjects above the top tertile of baseline BMI and Sichieri, et al. (35) had reported more nearly significant results among subjects overweight at baseline, we tried to conduct an analysis of only subjects exceeding the top tertile (i.e., in the upper third) of the baseline BMI distribution or of a subset deemed overweight at baseline. Such information was already available for Ebbeling, et al. and for Sichieri, et al. We wrote to the remaining authors to request information on an analysis of just subjects in the upper third of the baseline BMI distribution. One author (Munoz) provided the requested analyses. Thus, we were able to meta-analyze only 3 studies in this fashion.
As indicated in Table 6, the overall estimate of standardized mean difference in BMI was 0.349 (SE = 0.071) and was statistically significant (P <0.0001; 95% CI: 0.211 to 0.488). The Q or χ2 test of heterogeneity was not significant (P = 0.468) and the I2 statistic, an indicator of the magnitude of among study heterogeneity in outcome was 0.00%. These results indicate that there was a statistically significant effect overall, that the best estimate is that interventions of the types studied to date could produce roughly a 0.35 standard deviation unit lesser BMI change (i.e., more weight loss or less weight gain) in treated versus untreated subjects who were overweight or in the upper end of the BMI distribution at baseline, and that the results appear consistent from study to study. However, given the possibility that such subgroup analyses are more likely to be reported when they are statistically significant, reporting bias (61-63) may have contributed to this observation, and there is evidence that closely related forms of bias may hold on the topic of NSB consumption and obesity (MB Cope and DB Allison, unpublished observations, 2009).
Second, one could argue that the entire study by Albala, et al. should be included in this subgroup meta-analysis because all subjects were overweight at baseline. Had we included that study, the overall meta-analytic effect size estimate would remain significant, but would be reduced from 0.349 to 0.285. One might question why the Albala, et al. study did not obtain a statistically significant result in the predicted direction if there is truly an effect of NSB reduction programs on BMI among initially overweight persons. One reason may be the substitution of milk for NSBs as discussed above. The other may be power. Let us assume for the moment that there is a true effect of such programs aimed at NSB reduction on BMI change scores with an effect size of 0.349. In that case, a 2-group parallel-arm RCT with equal allocation to each group and no cluster randomization or dropout would require roughly 263 subjects to have 80% power at a 2-tailed alpha level of 0.05 or roughly 497 to have 90% power at a 2-tailed alpha level of 0.01 [calculated with publicly available software (64)]. Thus, the Albala study may have been markedly underpowered with a sample of only 98 subjects.
A study by Williams, et al. (34) evaluated weight loss in overweight adolescents assigned to 1 of 2 dietary interventions differing in the types of snacks allowed. In this 12-week, controlled clinical trial, otherwise healthy but overweight 10-y-old to 16-y-old girls were randomly assigned to either a 1500-kcal/d (6280-kJ/d) free-snack (FS) diet or an isoenergetic restricted-snack (RS) diet. In addition to consuming 3 meals, subjects in the FS group could choose any 150-kcal (628-kJ) item as 1 of their 2 daily snacks, including regular soda (12 oz, 355 mL), if desired. The other snack had to be chosen from a list of "healthy" snacks. Subjects in the RS group also consumed 3 meals and 2 snacks per day; however, both snacks in this group were restricted to the healthy snack list, which included only sugar-free beverages (e.g., diet soda). Treatment in both groups included parent/family support counseling, frequent assessment and monitoring, behavioral counseling, guidelines for dietary intake, and specific physical activity goals. Thirty-two of 38 subjects enrolled in the study (84.2%) completed the 12-week intervention.
In total, 29.4% of the girls in the FS group drank an average of one to two 12-oz servings of regular soda per week, 41% of the girls drank an average of three 12-oz servings of soda per week, and 29.4% consumed a mean of more than 3 servings per week. In the RS group, 16.6% of girls consumed 1 or 2 servings of diet soda per week, 25% consumed a mean of 3 servings per week, and 58.3% consumed more than 3 servings weekly. Mean weekly consumption of regular soda was about 3 servings in the FS snack group, whereas mean weekly consumption of diet soda was slightly more than 4 servings in the RS group.
Weight loss and changes in BMI over the intervention period were similar in both diet groups. The mean weight loss was −1.32 kg in the FS group and −1.22 kg in the RS group. Mean BMI decreased by −1.00 kg/m2 in the FS group and −1.05 kg/m2 in the RS group. The authors concluded that the results of this study showed that both diets were equally effective in achieving a modest amount of weight loss and "that some soda may be included in a teen weight control diet, as long as caloric intake is maintained at recommended levels, and care is taken to achieve adequate intake of essential nutrients."
This study affirmed the prepotency of total energy on weight change. NSBs exerted no apparent effects over and above their contribution to total energy intake. However, the absence of data on energy expenditure precludes definitive resolution of this issue.
Several studies did not match our a priori inclusion criteria but are still instructive. In one, 12 healthy, 18-25-y-old men with documented weight stability were provided a daily non-energy yielding sweet beverage supplement (placebo) for 3 wk and a 1000-kcal (4184-kJ) beverage supplement, matched to placebo on sensory properties, for 8 wk (65). All supplements were consumed between 2200 and 2300 hours. The treatment order was not randomized, hence its exclusion from our analysis. Weekly weight change during placebo and supplement consumption was 0.11 pounds (0.05 kg) and 0.86 pounds (0.39 kg), respectively, which was described as a highly statistically significant difference by the authors (no test statistics given). Dietary compensation for the supplement was approximately 50%, so the change in weight was roughly consistent with the estimated excess energy ingested (~500 kcal/d, ~2093 kJ/d). Fixing the time of beverage ingestion to late evening and lacking non-sweet and non-beverage controls precludes attributing the weight gain to any specific property of NSBs.
Another intervention trial with 21 children aged 6-13 y involved monitoring beverage and food intake, as well as body weight, in a camp setting for 4-8 wk (67). The children had unlimited access to water, milk, and a fruit-flavored sweetened beverage. The lack of random assignment accounts for its omission from the present analysis. Milk consumption elicited a weak reduction in solid food intake; the fruit juice was less effective, resulting in an increase of 244 kcal/d (1022 kJ/d). Children consuming >12 oz (355 mL) of fruit beverage per day gained 3.3 ± 1.95 kg, whereas those consuming <6 oz/d (177.5 mL) gained 0.5 ± 0.4 kg (difference not significant). The marked, albeit non-significant, increments in weight gain associated with higher consumption of NSBs or milk are notable, but the design does not permit conclusions about a unique role played by NSBs because the study lacked controls for beverage properties, such as palatability, as well as food form.
A third trial reported stronger dietary compensation than some other trials and no weight change among 28 adults randomly assigned to consume "Irn Bru" or "Diet Irn Bru" (a sweetened [sucrose], citrus-flavored, carbonated and caffeinated beverage) for 7 d (66). However, there was a rank ordering in which children who drank more NSBs gained more weight. The females and males consumed 2.4 ± 0.6 bottles/d (about 240 kcal, 1005 kJ) and 2.9 ± 0.5 bottles/d (about 290 kcal, 1214 kJ), respectively. However, the validity of the diet records was not assessed. Furthermore, the short duration of intervention and small sample size precluded detecting meaningful changes in body weight. The former concern was the basis for excluding the trial from the present analysis.
A fourth trial reported no difference in change in body weight or percent body fat in 63 Marines consuming Unitized Group Rations in addition to unrestricted amounts of either a supplemental carbohydrate beverage (8% maltodextrin) or a supplemental placebo beverage sweetened with a non-nutritive sweetener (aspartame) for 11 d (68). Total daily fluid intake was not different between the groups (placebo group, 7.7 L/d versus carbohydrate group, 7.3 L/d). However, supplemental beverage intake was 30% higher in the placebo group than in the carbohydrate group (placebo group, 3.1 L/d versus carbohydrate group, 2.3 L/d). The short duration of the intervention made the detection of changes in body weight and percent body fat in this study problematic. In addition, study subjects could be considered to have been severely stressed because they were participating in a field artillery exercise under windy conditions and daily temperatures of up to 31.9 °C. This study was excluded from consideration for both of these reasons.
Two recently reported studies also were excluded for different reasons. The first, a clinical trial of the effects of goji juice on general health (including measures of adiposity) (69), was excluded because of the short study duration (14 d). In this study, there was no significant difference in change in BMI in subjects randomized to either a group consuming 120 mL/d of goji juice (n = 16) or to a group consuming an equal amount of placebo control solution (n = 18). The second, a study evaluating the effectiveness of a school-based nutrition education program on nutrition knowledge, attitude, and self-reported behavior (including NSB consumption) (70), was excluded because there was no apparent randomization of the treatment conditions, nor was there any outcome related to adiposity.
Figure 6 summarizes our assessment of potential areas of bias in the ways the included studies were conducted and reported. We assessed the various categories of risk based on the available information. It should be noted that the nature of these studies make it very difficult, if not impossible, for participants to be blinded to their randomization group. This should not be interpreted as bias on the part of the design or researchers per se.
Our meta-analysis shows that the currently available evidence on NSB consumption reduction programs is suggestive, but does not confirm that such programs may be effective, particularly in persons who are overweight or obese at baseline. A well-powered and adequately controlled RCT to test this specific hypothesis is clearly needed.
As stated in the outset of this review, recently published critical reviews and formal meta-analyses on the role of NSBs in overweight and obesity have yielded discrepant findings or conclusions (16-19). Some clarification is required to help resolve this issue and move the field forward. Focusing first on the meta-analyses, they are based on different subsets of the literature. Vartanian, et al. (17) included cross-sectional, longitudinal, and experimental studies, whereas Forshee, et al. (18) limited their analysis to longitudinal studies and RCTs. The effect sizes for the cross-sectional and experimental data are stronger (0.08 and 0.24, respectively) than is the effect size reported by Forshee, et al. (0.017; random effects model), thereby accounting for some of the interpretative difference.
Differences of professional judgment also factor into the discrepant conclusions. Forshee, et al. (18) believed it appropriate to control for energy intake in their analyses, while this has been questioned by others (71) on the grounds that it is the mechanism by which NSBs exert their effect on body weight. If beverages contribute to positive energy balance through weak satiation effects and poor dietary compensation, controlling for energy intake might preclude identification of a treatment effect and account for the different conclusions.
Another important distinction is the focus by Forshee, et al. on studies of children and adolescents. In their analysis of the longitudinal studies, Vartanian, et al. (17) included 3 studies of adults, which yielded an effect size of 0.09 compared with 0.017 by Forshee, et al. (18). In a subgroup analysis by Vartanian, et al., they acknowledge that the association between NSB consumption and BMI was stronger in adults.
Differences in search strategies also apparently yielded different papers for analysis. Most notably, a study included by Forshee, et al. twice in their analysis [boys and girls separately; a study by Mundt, et al., 2006 (72)] had the largest negative effect and was not included in the analysis by Vartanian, et al., which accounted for another increment in the difference in effect sizes. Differences in qualitative analyses and underlying assumptions of the reviews are also notable, because they influence the tone of the reviews. For example, Forshee, et al. (18) questioned the validity of the dietary data from a study reporting a positive association (26), yet argued for the validity of the dietary data in their overall analyses, which concluded there was no meaningful association between NSB consumption and BMI. In contrast, errors in dietary assessment were recognized as a source of potential error in a review emphasizing an association between NSB consumption and BMI (16). Forshee, et al. (18) also remarked that a particular study reporting a positive effect did not use a nationally representative sample (73), yet this limitation applied equally to most of the studies noting no or a negative association. The issue of singling out the one study aside, some might argue that the burden of proof of the validity of measurements lies more heavily with those reporting no effect, because large random error will often (although not always) (74) obscure associations and account for the lack of effect.
Finally, we believe that many of the studies included in these prior reviews were not designed to address the question of whether NSBs contribute to weight gain or hinder weight loss. Instead, they were tests of the role of sweetness, sweeteners, or education on these outcomes. NSBs are an important source of dietary sweetness and sweeteners, but to understand the role of NSBs, they must be contrasted with beverages that are not sweet and do not contain sweeteners as well as with non-beverage sources of sweetness and sweeteners. There appears to be only a single, small, short-term study meeting this criterion (22); obviously an inadequate basis for drawing conclusions.
Our review has several unique strengths. First, we sought out and included unpublished literature to avoid publication bias. Second, by focusing only on the experimental literature, we were better able to address causation as opposed to association. Third, the present approach allowed us to partition the experimental literature into distinct categories that differed in terms of the fundamental questions asked. As a result, we believe we demonstrate that several studies that previous reviewers included in the experimental category or in reviews of NSB effects did not merit inclusion. Fourth, we conducted a meta-analysis specifically in the subset of subjects with high baseline BMI values (i.e., typically those that were overweight or obese).
Our review was limited to selected beverages and their effects on body weight, so the conclusions should not be extrapolated beyond those targeted. Different beverages may well hold varied implications for energy balance (75). For several beverage classes (e.g., coffee/tea, sports drinks, fruit juices, alcohol), their independent effects (if any) may differ from those of NSBs. In other cases, the appropriate controls are not available. The effects of liquid meal replacement products on weight change are an example. Their effects have been reviewed previously (19, 76, 77). However, these studies generally replaced energy from solid foods with liquid meal replacement products while holding total energy intake constant; therefore, any effects of liquid meal replacements compared with solid foods on satiation and subsequent energy intake (possible mechanisms through which NSBs could affect weigh change) could not be assessed. Accordingly, these studies were excluded here.
There is also an interesting potential clinical implication. Future research may support the conjecture that reducing NSB consumption is not effective for most persons, but is effective for a subset of persons who are predisposed to or are already overweight. Should this come to pass, then as Durant, et al. (78) suggested, clinical recommendations and public policy measures might be better designed and meet less resistance from the general public to the extent that they can successfully meet the needs of the susceptible group without placing undue restrictions on the populace overall. The size of this subgroup warrants further consideration as it may range up to 67% of the population (the currently overweight and obese).
This critical review of the literature suggests that the current evidence does not permit definitive conclusions about the effects of reducing long-term consumption of NSBs on BMI. This is due, largely, to the fact that few studies focused directly on the topic and thus were not appropriately designed to answer the question. Studies contrasting effects of consuming beverages with and without energy-yielding sweeteners do not provide insights on whether obtaining energy from beverages poses a particular risk. Contrasting responses to semi-solid and solid food forms is required to address this point. Neither do studies of sweeteners that do and do not provide energy determine whether sweeteners are especially problematic. Both are sweet, and sweetness may have independent effects on intake (79, 80). Comparisons of responses to beverages containing non-sweet energy sources, such as fat and protein, are essential to isolate the role played by sweeteners. Evidence from short-term feeding trials suggests that there is limited energy compensation for any of the macronutrients in beverages (5).
There is fairly strong experimental evidence that requiring subjects to consume additional energy in the form of NSBs increases weight (see Table 7). In contrast, while the totality of evidence relevant to the proposition that reducing NSB consumption will decrease weight, rate of weight gain, or the probability of being obese is suggestive, findings from RCTs are not supportive overall. However, these were effectiveness, not efficacy studies. As such, they may merely indicate that we are not yet terribly effective in getting people to reduce NSB consumption rather than showing that reducing NSB consumption per se does not reduce BMI. As noted elsewhere and in Table 7, rigorous long-term (i.e., ≥12 mo) efficacy (not effectiveness) studies of NSB reduction may be the next best step to determine whether reducing NSB consumption will reduce BMI or obesity levels. That being said, there is some evidence (Table 6) from the existing effectiveness trials that applied programs to discourage NSB consumption may have modest beneficial effects on BMI change among persons in the top one third of the BMI distribution. We calculate that, assuming a non-cluster randomized 2-arm parallel groups design, an RCT concluding with 300 to 500 subjects (and presumably randomizing more) might be required to test this hypothesis with adequate power.
Although it is often preferable to establish the existence and probable consequence of a phenomenon before embarking on mechanistic studies to support it, the suggestive evidence reviewed here, coupled with published epidemiologic and short-term feeding trials, provides reasonable grounds to pursue mechanistic questions as a second level of investigation. For example, if NSBs promote positive energy balance as a result of their weak appetitive properties, what sites in the normal regulatory system are responsible? Options include, but are not limited to, cognition, orosensory signaling, gastrointestinal transit, differential activation of gut satiety mechanisms, rate of absorption, and post-absorptive endocrine responses. Mechanistic studies will provide support for noted effects in RCTs, contribute to understanding of ingestive behavior and physiology generally, and highlight intervention targets, should they be desirable.
The high incidence and prevalence of overweight and obesity and plausibility of NSB consumption as a contributor have prompted several feasibility trials where educational interventions aimed at curbing use were evaluated for effects on body weight (26, 28, 31). Such effectiveness studies might be considered a third-tier research need until the causal influence of NSB reduction per se and probable mechanisms can be established in efficacy trials. Knowledge of the latter will inform the design of the most efficient and effective clinical and public health management approaches.
It is apparent from this review that certain areas exist where further research may not be productive. In our view, continued conduct of observational studies correlating NSB consumption with aspects of adiposity has little merit. At this point, the question of the effects of NSBs on weight has been called; a hypothesis has been made. Only randomized experiments can provide the answers needed. Continued observational work in this area will offer more heat than light.
The effects of NSB consumption on body weight are difficult to discern. Considerable support for a direct association may be drawn from a diverse literature, but evidence from more definitive RCTs is lacking. Policymakers need act on the pressing problem of overweight and obesity, which regrettably means that decisions must now be made on imperfect knowledge. Understanding the risks associated with missteps, it is imperative future efforts be focused on the science most likely to fill current gaps in knowledge. In our opinion, this entails RCTs combined with targeted mechanistic studies, especially among those overweight or obese at baseline.
We thank Dr. Daniel Munoz for graciously supplying us with additional information about and analytic output from his study on several occasions. This activity was supported in part by NIH grants P30DK056336 and 5R01DK63185. The opinions expressed are those of the authors and not necessarily those of the NIH or any other organization with which the authors are affiliated.
Competing Interests: Dr. Allison has received grants, honoraria, donations, and consulting fees from numerous food, beverage, pharmaceutical companies, and other commercial and nonprofit entities with interests in obesity, including but not limited to Merck, Pfizer, Eli Lilly Co, Abbott Laboratories, SlimFast Foods, Frito-Lay, Kellogg Co, the Coca-Cola Company, PepsiCo, McDonald's Corporation, the NY State Restaurant Association, the Dairy Council, General Mills, Kraft Foods, and PomWonderful. Dr. Mattes has received grants, honoraria, and consulting fees from numerous food, beverage, pharmaceutical companies, and other commercial and nonprofit entities with interests in obesity, including but not limited to the Eli Lilly Co, Abbott Laboratories, SlimFast Foods, Kellogg Co, Kraft Foods and the Dairy Council. Dr. Shikany has received grants and consulting fees from food companies with interests in obesity, including General Mills and Frito-Lay. Dr. Kaiser has no competing interests to report.
Ethical Approval: Not required.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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ZTE Nubia Z7 Max
The Chinese brand ZTE knows the users requirement, so has introduced a phablet ZTE Nubia Z7 Max. A powerful smartphone, specially created to enjoy multimedia content with its 5.5 inches screen, but not only that, because it has a performance at the level of high-end, providing power and memory to move all kinds of demanding applications and games. A terminal with many possibilities discussed in detail below:
The terminal ZTE Nubia Z7 Max features a 5.5-inch dsiplay that puts it in phablet category. A screen that also has Full HD resolution reaching 1920 x 1080 pixels. The pixel density per inch reaches 403 ppi, which together make an ideal place to enjoy HD content.
ZTE has also kept the sefie in their mind while making this device., and has included 5-megapixel front facing camera. It can help you to capture your own picture or video in good quality, but this might make a good and bad effect while making video calls using data. Good thing is not for you but the other person who talk to you is that he/she can enjoy great video quality while talking to you, but you will lose more data. If you are on unlimited plan or WiFi, that is going to be amazing. The rear camera is 13 megapixels that can capture pictures in 4128 x 3096 pixels resolution. It also has all kinds of photography functions for stunning images such as panoramas, face detection, HDR and of course has an LED flash.
ZTE Nubia Z7 Max has a Qualcomm Snadpragon 801 quad core 2.5 GHz processor and 2 GB of RAM. So this device is able to run all the applications and games without slowing down the system, and can even enjoy multitasking of several applications smoothly. Nubia Z7 Max has 32 GB internal storage, and has a MicroSD card slot, that supports up to 64 GB . You can also use cloud storage on to of that. The ZTE Z7 Max comes standard with the 4.4.2 version of Android OS, known as KitKat, and ZTE also has a custom skin called Nubia UI which is its own user interface. This model is 4G LTE equipped, and supports two SIM (dual stand-by). ZTE has included a 3100 mAh battery with this phablet that is good enough for such device according the other devices available in the market.

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Gold Jewelry
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La Voix Studio
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La Voix Studio is the studio where singers develop and improve their voices. We are located in Studio City operated by a top vocal coach and celebrity professional singers. Our owners and staff consist of a former lead singer of a top female selling group in the world, celebrity vocal coaches, professional musicians/singers and musical conductor from a top record company that has worked with many hit recording artists. Along with the grace and blessings of our celebrity friends and family that support us. Our studio offers private vocal lessons with top instructors, group sessions, sight reading classes, singer's classes, master classes and online lessons. We also offer piano, guitar, bass and trumpet lessons. We help our students prepare for auditions, expand their range, enhance their power, strengthen their voice and eliminate their breaks, all to gain control and preserve the longevity of their voices. If you have any other questions or would like more information about our studio, please visit our website.
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Feb 2, 2015
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Shoshana is so great and helpful! Her lessons never leave my voice feeling tired or strained, and I've been noticing improvement already (only 2 lessons in!). Shoshana is also very good at communicating a concept to you. I also find the recordings of each lesson extremely useful!
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It was great I really enjoyed my lesson.and it was my first lesson.she was ontime and vvery kind teacher I really appreciate it.
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Shoshana is an amazing teacher! I started voice lessons with her for just a year and I've already improved so much. My friends and family have all noticed a significant difference. I feel much more confident in singing in front of people now. My range has increased and my tone sounds a lot better than when I first started. At first, I was a little hesitant about starting voice lessons, but she made me feel very comfortable and at ease. She knows exactly how to take your voice to the next level. I recommend Shoshana to all my friends. Take her lessons! You won't regret it!
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Superb. The studio had a great energy, everyone in the studio was kind and happy. Shoshana has a true gift, she articulated everything in a way that was super clear to a beginner (me), pin point what I need, give me a clear direction of where we're headed, and make me feel super comfortable and at ease. I'm going back this week.
Annie H.
Sep 24, 2014
I have been taking vocal lessons with Shoshana Phillips at La Voix Studio for over 4 years and have always had a wonderful experience. In my opinion, she is the best vocal teacher in all of Los Angeles. She has a great ear and understands exactly what her students' weaknesses and strengths are, and works from those areas in order to build vocal strength and confidence. I highly recommend her as a vocal coach, and she is also a kind and understanding person. If I could give more than 5 stars I would!:)
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La Voix Studio is amazing. As a beginner, I feel so privilege to be working with a professional teacher.
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The typical process for working with a new student is asking students what their level is and what their goals are because that will depict what teacher they will study with. If students do not know their level or it has been a while since they have had lessons, we offer complimentary vocal consultations which is how we can assess their voice, see where they are vocally and let them know exactly what we would need to do in order to reach your goals.
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I have been singing all of my life. I grew up with a musical family. I have a degree in Liberal Arts, Bachelor of Science in Business Management, Masters in Public Administration & recently obtained a second Masters degree in the Art of Teaching English from the University of Southern California. I believe in continuing education to stay up to date on the latest developments. I am currently pursing my PhD in Music Education. You can never learn everything but it's worth it to try to master your craft. Learning is a great thing and a powerful tool.
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Boutique Hotel & Exclusive-use Wedding and private event venue
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Grimsby - 22 miles
Hull - 20 miles
Lincoln - 20 miles
Market Rasen - 16 miles
Scunthorpe - 6 miles


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Question 63
July 18, 2012 Posted by Levi Maestro
Where did the name for your brand STRO originate from?
Submitted by Bisrat Teklu. July 18, 2012
|Some of my friends call me STRO, short for Maestro. I like it a lot, always felt like it fit. Plus I wanted a name that was very simple & vague, so that it could eventually be bigger than me. Maybe right now the people who know about STRO, know about because of me but in the future people will find out about only because they know of STRO.
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Their isn't a movie filled with more woe, than that of Juliet and her Romeo. I'm a little offended by this film. I think they did a lot of things wrong. The casting was not that bad, just a lot of other things were. I've performed in this play and was shocked at some of their choices. Like throwing away the balcony scene like it didn't consist of some of Shakespeare's most famous lines. Also, the Nurse and Peter had little to no comedy, when they were written for levity in all the tragedy. Poorly done, and it makes me sad.
For more information on this film,
visit the imdb.com page:
Romeo and Juliet (2013)


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Sign up for NWRPCA's monthly newsletter, Northwest Pulse, and stay up-to-date on the latest community health center innovations and trends.
Northwest Regional Primary Care Association is a member organization that strengthens community and migrant health centers by leveraging regional power and resources on their behalf.
|Business Intelligence for Region X (BIX)
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NWRPCA's Business Intelligence for Region X program, referred to as BIX, supports community and migrant health centers (C/MHCs) in identifying, collecting, analyzing, and utilizing data to best address the Triple Aim — improving the patient experience of care and the health of populations, and reducing the per capita cost of health care — as well as the transition to value-based payment methodologies.
With assistance from key NWRPCA partners, data is collected from participating member and non-member C/MHCs. That data is aggregated, analyzed, and shared with participating C/MHCs to help them make optimal business and care delivery decisions.
NWRPCA currently accomplishes this through two opportunities:
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"Instead of the noisy squawks and atonal meditations of free jazz, Martin's interest in the horn's extended techniques lies in a more quietly lyrical and painterly expression of his themes...a charmingly expressive alternative to some of the more in-yer-face enterprises in current UK jazz." ★★★★ Selwyn Harris – Jazzwise, August 2016
"John Martin has succeeded in integrating multiphonics and the overtone series on his saxophone into 10 beautiful compositions. He's found his own way to do this, and the result is beautiful and compelling. He's certainly found the "notes between the notes"!" Bob Mintzer
"Few new releases come with quite such a specific technical claim as this double release from British saxophonist John Martin…Martin's originality is explorative rather than explosive…a technique of infinite subtlety and a restless sensitivity that ruffles and wrestles with existing modes of expression…The understated brilliance of the multiphonics is Martin's defining feature" ★★★★ Matthew Wrighter – The Arts Desk
"John Martin has thought (and realised) the unthinkable; harnessing all the multiphonic sounds that a saxophone can make, he has crafted them within the finest compositions. No small feat. These resources are hard to control, and it is a patient labour ofsome love for the instrument that he has succeeded where others have not dared tread... not just the gimmick of one squawky tune, but a controlled double album of surprises and varied emotion... A milestone for both himself and the saxophone world" Barak Schmool – Founder of the F-ire Collective
"Highly distinctive... I was very impressed with "Spirit Of Adventure... Martin is one of the first saxophonists to make such wide ranging use of multiphonics and overtones in the context of through composed tonal music...this is a very well balanced and well integrated group...that gives full reign to Martin's innovative saxophone techniques" ★★★★ Ian Mann – Thejazzmann
John Martin Tenor Saxophone, Tim Giles drums, Ralph Wyld vibraphone, Tim Fairhall double bass, and Rob Updegraff Guitar.
The Hidden Notes offers a window into a unique and sonically facinating soundworld. It is a celebration of the saxophone and all the beautiful colours that are hidden just beneath the surface - ethereal, delicate two-note whispers, rich full chords, earthy split-notes, drones and powerful metallic dissonance. Circular breathing then allows for the development of continuous rhythmic patterns opening up many new exciting rhythmic and textural possibilities.
The record has been mastered by the grammy award winning mastering engineer Mandy Parnell and is available as a double CD digipack and digital download from this website and all good record stores.
Link to iTunes for digital downloads - https://itunes.apple.com/gb/album/hidden-notes-spirit-adventure/id1120941840


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Jamie Ram
Ram is a former Canadian professional ice hockey goaltender. He was drafted in the tenth round, 213th overall, by the New York Rangers in the 1991 NHL Entry Draft. Jamie Ram also played for the Colorado Avalanche, but only for one game. In that game, he stopped all nine shots that he faced.


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Retold by: Layne MacPherson
Snow White, the Seven Dwarves and Their Rights
Once upon a time, a fair maiden named Snow White spoke out against the evil queen. This didn't make the Queen very happy, so she banished Snow White from her kingdom, infringing on her first right.
Snow White was terribly frightened, so she ran into a small hut at the edge of the woods. There she saw a moonshine distillery, because of a law passed that prohibited alcohol.
Once inside the hut, she was shot in the leg by a small, gun wielding man, for he had the right to bear arms. boom
Snow White went to court, which was watched over by a jury, and sued the dwarven family for 5,000 jewels. Thankfully, the court ruled this as overly excessive and nullified her claim
Still angered by this injustice, Snow White told an army to search the home of the dwarves, but the dwarves would not allow it, due to the fact that there was no search warrant.
The army was exhausted after this long day, but knew that they could not quarter themselves inside the moonshine distillery house. So they went on their way.
All this time, the dwarf's slave Dopey was working in the mines giving them diamonds and other precious stones. Meanwhile, Snow White pulled some strings and passed a law to abolish slavery
Angered by the loss of their servant, the dwarves buried Snow White alive, but were witnessed in the process by the Prince.
The dwarves quickly claimed the privilege to be tried in front of a grand jury and demanded their rights to a fair and speedy trial. They also said that they had a set of unalienable rights.
The Prince contacted his friend Duke Madison, who was called the father of their kingdom's Constitution and asked if he could become the supreme ruler and judge, but the Prince was denied his request because power was limited in their kingdom
The Prince then went to his room and cried for a long time, for his love was murdered and he was denied power.
Epilogue The dwarves were found guilty and were sentenced to a life in prison. The Prince took therapy and soon recovered from watching his love be murdered. The Queen died and a King took her place. Under his rule the alcohol ban was repealed three amendments later and Dopey started a successful whiskey distillery at the home where he once was enslaved.
The End
Pictures: All from Google Images 1.http://en.wikipedia. org/wiki/List_of_amendments_to_the_United_S tates_Constitution 2.http://www.youtube.com/watch? v=pIKhRERqPS4 3.
Published on Oct 19, 2012
story for Queen Beav


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A Hubber I have known for about 2 years has been getting lots of "substandard" notices when she posts and as she is not getting any responses to emails she sends. It is frustrating for her. I know Hubpages had a bug sometime, which was affecting many articles and we were asked to notify you via email.
Is there an alternative email?
Thanks for any responses. I have asked her to follow this post up.
In the thread where hello, hello was writing about her substandard problems, one of the moderators replied and said how they will not respond when a Hub user continually writes to them with the same questions over and over after they have responded to that person.
So that's her problem with not getting a response, not the email address she's using. Not only that but various Hub users have identified why her Hubs are now considered substandard in the post-Panda web world.
Ok. Thanks Relache.
I just wanted to be of help, as she said she wanted to leave HP.
I appreciate your response.
Regards, Elena.
by Mary Craig4 years ago
Wouldn't it be nice if some explanation about the hub came with the above mentioned notices. All you get is the general notice that you hub is overly promotional or substandard and it needs to be fixed. If...
by hspatel13126 years ago
I am new hubber. When my 3rd day I have 14 articles published And I also got ACCOLADES for 10 hubs. And the next day I receive mail. And when checked my account there were all hubs needs revision!!!! how is this...
by Karen Wilton6 years ago
I've been on here for 9 months and followed all the advice from the learning centre, forums and hubs from the best hubbers. I earned the first $24.00 in the first month and I'm only $1.00 ahead for the next eight. What...
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I have a hub that is doing well (at least for me, as a beginner), but is not monetized because it has one swear word in it. I have written the team twice asking them if they would look at it and remove the filter. They...
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Is there a possibility we could have a new feature that would only allow Hubpage members with profiles to send emails? I think this might cut down on the amount of spam we are currently receiving from unverified...
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Want to see some amazing low quality hubs? Go to the top of the page, click hubbers, then click "latest". There will be a few good ones but at least half are spam and many hubs are just a few sentences, often...
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Do you feel like you're walking through life's valley? These devotionals can give you strength.
Under the old covenant, there were rules governing the places where worship might be offered but under the new covenant the earthly location is of no importance.
Ge 12:7 See also Ge 8:20; Ge 26:23-25; Ge 35:1
Dt 12:13-14 See also Ge 22:2; Dt 14:23-25; 1Ch 21:18-19; 2Ch 7:15-16
Dt 12:5 See also Ex 3:12; Dt 26:2; 1Sa 1:3,28; Isa 27:13; Jn 4:20
Ex 25:8-9 See also Ex 29:42-43; Ex 33:10; Lev 17:1-5
1Ch 22:1 See also 2Ch 7:15-16; 2Ch 29:27-30; Ne 8:6; Lk 1:8-10; Lk 2:37; Ac 8:27
Lk 4:16 See also Ac 13:15; Ac 15:21; Ac 17:2
Da 6:10 See also Mt 6:6; Ro 16:5; 1Co 16:19; Col 4:15; Phm 2
Jn 4:21-24 See also Ge 24:26; Ge 47:31; Jdg 7:15; Job 1:20
Lk 2:13; Heb 12:22; Rev 4:9-11; Rev 5:13-14; Rev 7:9-12; Rev 19:4-7
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A signature DVF wrap dress in fine silk, detailed with a classic leopard print. Long sleeves and split cuffs. Unlined. Fabric: Silk crepe. 100% silk. Dry clean. Imported, China. Measurements Length: 49.5in / 126cm, from shoulder Measurements from size 4
A vibrant DVF sheath dress in a classic curve-hugging profile, fashioned with an optional, striped belt. Subtle seams contour the bodice, and a back slit divides the hem. Scoop neck and back. Short sleeves. Hidden back zip. Unlined. Fabric: Stretch crepe. 70% triacetate/30% polyester. Hand wash or dry clean. Imported, China. Measurements Length: 41in / 104cm, from shoulder Measurements from size 4
Promo code: SHIPONUS
The New Jeanne Two wrap dress is a modern take on the timeless classic. It's as fresh, flattering, and chic as ever. Cross over wrap with straight skirt and a self-tie belt. With collar. Long sleeves. In our seasonless silk jersey. Unlined. Fit runs small. Our signature medium to lightweight silk jersey with stretch. 58 cm/ 23 in from natural waist Style #: D5130001E00 Color ID: CHNLM
Simple lines lend timeless elegance to this knit DVF wrap dress. Tie closure. Long sleeves. Unlined. Fabric: Crepe knit. 83% viscose/17% polyester. Dry clean. Imported, China. Measurements Length: 35.5in / 90cm, from shoulder Measurements from size S
Promo code: SHIPONUS
A wardrobe staple, New Julian Two is the classic wrap dress. Collarless, 3/4 length sleeved true wrap with self-tie belt. In our seasonless silk jersey. Falls to above the knee. Fit runs small. 23" from natural waist Style #: D5131001E00 Color ID: CHNLM
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A summery shirtdress of fresh white cotton takes classic feminine form in a fit-and-flare silhouette with knotted ties slimming the waist in an effortlessly casual way. Brand: DIANE VON FURSTENBERG. Style Name:Diane Von Furstenberg Cotton Shirtdress. Style Number: 5356548. Available in stores.
Promo code: SHIPONUS
This above-the-knee, long-sleeve shirt dress looks great worn alone or over a pair of jeans. Cut in a cotton-silk blend, it features a button-down closure, a self-tie belt, and cuffs with a three-button closure. Estonia Leather Sandal 72% Cotton 28% Silk Style #: 10024SWM Color ID: CRLBA
Lightweight cashmere lends a luxurious feel to this signature DVF wrap dress. V neckline. Tie closure. Long sleeves. Unlined. Fabric: Knit. 100% cashmere. Dry clean. Imported, China. Measurements Length: 37.75in / 96cm, from shoulder Measurements from size S
This ladylike Diane von Furstenberg shirtdress has vintage charm with a tie detail at the nipped waist. Fold-over collar and button placket. On-seam hip pockets. Short sleeves. Unlined. Fabric: Polished shirting. Shell: 100% cotton. Trim: 84% polyester/16% spandex. Dry clean. Imported, China. Measurements Length: 40.25in / 102cm, from shoulder Measurements from size 4
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Wrap-style dress highlighted with vibrant patterns. Surplice neckline. Spaghetti strap. Self-tie at waist. Scarf hem. About 57" from shoulder to hem. Silk/polyester/spandex. Dry clean. Imported. Model shown is 5'10" (177cm) wearing US size Small.


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SaltyTON has won 6,931 Achievements in 494 games
Registered on 29 Aug 09
| Last visited 10 Sep 17 | Last scanned today at 17:37 by TA Scanner 4
Why they let people review a product they have never seen first hand blows my mind. I dont doubt it will be great, but without even touching one you cant give it a 5 star
lol I unhelpful and reported all of them lol
£450!!!! Lol no thanks il wait for a couple years.
^ kind of worth it in my opinion.
...there are
5 other comments
^ not for the people who don't understand hardware and that even though it is an Xbox "One" it's not the same console. Imo Microsoft should have made it entirely next gen
Its the same as in it plays the same shit the regular one does.
Sure. You can also make phone calls with a telephone from the 1940s same as in with a smartphone.
^^^^^^great example.
LOL. Not the same console? Don't understand hardware? Come on now. It's a technical upgrade, all games will have the exact same features. X will just look better.
37 achievements out of 45 won | 1,358 tracked gamers have this game | Last played 18 Sep 17
17 achievements out of 20 won | 36,776 tracked gamers have this game | Last played 27 Aug 17
| Given 4 stars by SaltyTON
40 achievements out of 40 won | 7,626 tracked gamers have this game | Last played 12 Aug 17
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Alan J Adler DDS
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Is this your practice? Claim & edit this profile.
Alan J Adler DDS has 1 doctor at 1 office location.
- (313) 839-7310
19150 Kelly Rd
Detroit, MI 48224
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Henry Smith Clothing Malaysia
Did you know Round Neck T-shirt (Black) and Nano Cool T-shirt (Black) are the most popular Henry Smith Clothing? There are more brands you can check out online such as OEM, Not Specified and Unbranded if you want more options apart from Henry Smith Clothing. From RM 85.00 to RM 812.00, you can get yourself a decent Henry Smith Clothing online. There are two main types ofHenry Smith Clothing, namely a T-Shirts, Cardigans and Pants. When it comes to color, Henry Smith Clothing today are most popular in White, Red and Orange.


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Peninsula College basketball roster
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Think about what career is best suited for you, and where you want to study. Request more information now.
Information about Peninsula College basketball roster, and registering for discussion sections and departmental seminars. Not all recruiting is done like NCAA Division I teams. College coaches like to watch video of real games. If you are interested in playing college sports, make a highlight film of your high school games, ready to send to coaches once you begin recruitment. Alternatively, post your videos online, for greater exposure. Finally, check with your major department for assistance with prerequisites, tuition payment deadlines, and Peninsula College Basketball information. Please use the form above to request admissions info for Peninsula College.
Always maintain a positive attitude, especially when you're in pain, or losing a game. Be a good sport, and keep trying. Believe you'll be successful, act like you can still win the game, and then go out and make it happen. Be aggressive, and make a second try on a given play if you have time. It's one thing to make a good effort, but great players keep trying until they succeed, no matter how many years of team practice that takes.
If you get lazy, and decide to take it easy during practice, coaches will take notice. Push yourself, work hard, and you'll improve as a player. It's important to find a position that you really like to play, not just settle for what you're good at. Over the long haul, you'll have a better athletic career. Niagara County Community College football game scores may indicate that it's an option to delay college entrance by a year. An extra year in high school or prep school can allow players to mature mentally, bring grades and SAT test scores up, put on weight and gain strength. Beyond consideration for Peninsula College basketball roster, you may think about Delta State University test scores for complementary electives to your primary course of study.
Fit Kids America
FLAG FOOTBALL COACHES NEEDED. Wants Youth Coaches. Be able to mentor and coach children ages 5-10.
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Coordinates the duties and responsibilities of any assigned Assistant Coaches or volunteers. Instructs and coaches athletes in performance skills and techniques..
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I9 Sports offers the best recreational youth sports programs in Ohio. We are looking for Baseball Coordinators to lead our 3-6 year olds this spring.
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At Northwest we aim to hire coaches who continually evaluate and improve the program based on the enthusiasm and achievement of players, communicate closely..
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