![]() The WHO guideline disregarded the trial evidence and solely relied on the prospective cohort studies, ignoring the established hierarchy of evidence as described by GRADE. When evidence comes from both trials and cohort studies, trials are given precedence. ![]() On the other hand, prospective cohort studies have less protection against bias and cannot establish causality, which is why they start at low certainty in GRADE. Randomization allows confounding factors to be randomly distributed, making it possible to establish a causal relationship between the intervention and the outcome. In the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to rating the certainty of evidence in systematic reviews and meta-analyses, evidence from randomized trials start at high certainty due to its greater protection against bias. However, results from the prospective cohort studies reported by the WHO SRMA suggested harm with NSS consumption based upon positive associations with BMI, incident obesity, type 2 diabetes, cardiovascular disease, and all-cause and cardiovascular mortality. ![]() These results unequivocally demonstrated that the mechanism of NSS benefit is through a reduction in energy intake. In addition, the WHO SRMA also showed that NSS led to reduced sugar and energy intake compared to caloric comparators. The demonstrated improvement to body weight, BMI, and energy intake outcomes in trials reported by the WHO SRMA are consistent with the results of several other SRMAs of NSS trials that have shown similar benefits for weight loss and BMI. ![]()
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