Sugar-Sweetened Beverages and Health: Studies in Adults

Frank M. Sacks, M.D.Nutrition Department, Harvard

School of Public Health

Acknowledgments

• Cara Ebbeling: Children’s Hospital, Boston• Frank Hu: Harvard School of Public Health• Miriam Vos: Emory University• Walter Willett: Harvard School of Public • Walter Willett: Harvard School of Public

Health

Sugar Sweetened Beverages

• Coronary Heart Disease• Diabetes• Obesity• Triglycerides and HDL• Triglycerides and HDL• Fatty liver• Sucrose vs High-Fructose Corn Syrup• Fructose vs Glucose

Sweetened beverages & risk of CHD:24-year follow-up in the Nurses Health Study

1.5

2

P<0.001

Rel

ativ

e R

isk

of C

HD

0

0.5

1

<1/mo 1-4/mo 2-6/wk 1- <2/d 2+/d

Rel

ativ

e R

isk

of C

HD

Sweetened Beverage Intake

Fung TT et al. AJCN 2009;89:10378.124

Adjusted for age, smoking, alcohol intake, parental history of CHD, physical activity, aspirin, postmenopausal hormones, hypertension, high cholesterol, and overall diet pattern.

Specific SugarSpecific Sugar--Sweetened Beverages and Risk Sweetened Beverages and Risk of Coronary Heart Disease in US women: of Coronary Heart Disease in US women:

Multivariate RRs for 2Multivariate RRs for 2--serving per dayserving per day

Beverage type RR (95% CI) P value

All1.28 (1.14, 1.44) <0.001

Colas1.35 (1.15, 1.57) <0.001

Carbonate non-colas 1.27 (0.87, 1.86) 0.22

Fruit drinks/punch1.33 (1.03, 1.71) 0.03

MV including diet (Fung TT et al. AJCN 2009;89:1037)

1.50

1.85

1.061.00

1.39 1.41

1.001.11

1.0

1.5

2.0

2.5

Relative Risk

P<0.001 for trend

Sugar-Sweetened Soft Drinks and Type 2 Diabetes, Nurses Health Study 2 1991-1998

1.00 1.00

0.0

0.5

1.0

<1/mo 1-4/mo 2-6/wk >=1/d

Sugar-sweetened soft drink consumption

Relative Risk

multivariate adjusted multivariate + BMI

25.079 Schulze M et al. JAMA 2004;292:927

Sugar-Sweetened Soda and Type 2 Diabetes in the Black Women’s Health Study

1.00 0.961.14

1.271.51

1.01.21.41.61.82.0

Rel

ativ

e R

isk

P<0.002

25.103 Palmer JR et al. Arch Intern Med 2008;168:1487

0.00.20.40.60.81.0

Rel

ativ

e R

isk

Sugar-Sweetened Soft Drink Consumption

<1/mo 1-7/mo 2-6/wk 1/day 2+/day

Singapore Chinese Health Study: Soft Drinks and Type 2 Diabetes

1.4

1.6

Soft Drink,p<0.0001Fruit juice.

RR

Odegaard AO et al. Am J Epidemiol 2010;171:epub

1

1.2

None 1-3/mon 1/wk 2+/wk

Fruit juice.P=0.03

Gestational Diabetes: Sugar Sweetened Beverages Increase Risk in US Women (N= 13475, cases = 860)

SSB consumption P for trend

0-3/mo 1-4/week ≥5/week 1 serving increment

All Sugar-sweetened beverages

Case/person-years 323/185,682 229/173,189 208/185,757

RR1 (95% CI) 1.00 1.01 1.23 1.25 (1.07, 1.45) 0.005RR1 (95% CI) 1.00 1.01 1.23 1.25 (1.07, 1.45) 0.005

RR2 (95% CI) 1.00 1.01 1.16 1.08 (1.01, 1.37) 0.048

RR3 (95% CI) 1.00 1.05 1.22 1.23 (1.05, 1.43) 0.01

Sugar-sweetened cola

Case/person-years 544/332,516 168/113,899 148/98,214

RR1 (95% CI) 1.00 1.12 1.39 1.39 (1.16, 1.67) < 0.001

RR2 (95% CI) 1.00 1.07 1.25 1.25 (1.04, 1.51) 0.02

RR3 (95% CI) 1.00 1.24 1.30 1.29 (1.07, 1.55) < 0.001

Chen L et al. Diabetes Care 2009;32:2236

74

76

78

80

Weight (in kg)

low-high-high

Regular soft

drink intake

'91 - '95 - '99

p=0.022

Sugar Sweetened Beverages and Mean Body Weight in 1991, 1995, and 1999:

Nurses Health Study II

66

68

70

72

1991 1995 1999

Year

Weight (in kg)

low-high-low

high-low-high

high-low-low

p=0.021

37.005Schulze M et al. JAMA 2004

Singapore Chinese Health Study: Soft drinks predict subsequent weight gain

Odegaard AO et al. Am J Epidemiol 2010;171:epub

Intake Sugar-sweetened soft drinks

1995 2001 N Mean weight gain* in kilograms(standard deviation)

Change in soft drink consumption and magnitude of weight gain: The Black Women’s Health Study

≤1/week ≥1/day 880 6.8 (0.28)

≥1/day ≥1/day 2,032 5.8 (0.19)

≤1/week ≤1/week 14,246 4.9 (0.07)

≥1/day ≤1/week 1,472 4.1 (0.22)

All others 11,057 5.5 (0.08)

Palmer et al. Arch Intern Medicine 2008

Added Sugar Intake Associated with Low HDL-C Levels Among US Adults

NHANES 1999-2006a

50

55

60

65

Mea

n H

DL-

C (m

g/dL

)

b

b

b

(referent)

a Error bars represent 95% confidence intervals; p-linear trend <0.001 bAdjusted mean is significantly lower than the referent, p<0.001

Source: Welsh JA, et al.. JAMA. 2010

40

45

0 -<5% 5 -<10% 10 -<17.5% 17.5 -<25% >=25%

Percent of total energy from added sugar

Mea

n H

DL-

C (m

g/dL

)

b

Added Sugar Intake Associated with Higher Triglyceride Levels Among US Adults

NHANES 1999-2006a

100

110

120

Geo

met

ric m

ean

trigl

ycer

ides

(m

g/dL

)

c

b

(referent)

c

a Error bars represent 95% confidence intervals; p-linear trend =0.02 bAdjusted mean is significantly higher than the referent, p<0.01cAdjusted mean is significantly higher than the referent, p<0.05

Source: Welsh JA, et al.. JAMA. 2010

90

100

0 -<5% 5 -<10% 10 -<17.5% 17.5 -<25% >=25%

Percent of total energy (kcals) from added sugar

trigl

ycer

ides

(m

g/dL

)

High Fructose Corn Syrup vs Sucrose

•High Fructose Corn Syrup

• Fructose 55%

• Glucose 41%

•Sucrose (table sugar)

• a disaccaride

• 50% fructose and 50% glucose

37.004

Fructose Metabolism

Elliot et al, 2002 Am J Clin Nut

• In animal studies, chronic fructose feeding causes fatty liver (along with….– Insulin resistance– Hypertension– Plasma hypertriglyceridemia– Plasma hypertriglyceridemia– Visceral obesity – Oxidative stress

Vos 2010

Fructose vs Glucose: Abdominal Fat Content

Stanhope et al.J Clin Invest 2009;119:1322

(Sweetened beverages, 25% of energy requirements for 10 weeks)

Glucose Intake Increases Blood Glucose Concentrations More Than Fructose Intake in Women

FIG. 1. Plasma glucose concentrations during a 24-h period (0800–0800 h) in 12 normal wt women consuming high glucose or high fructose beverages with each meal. Teff et al, J Clin Endo Metab 2004.

FIG. 2. Plasma insulin concentrations during a 24-h period (0800-0800 h) in 12 women consuming HGl or HFr beverages with each meal

C opyright ©2004 T he Endocrine Society

Teff, K. L. et al. J Clin Endocrinol Metab 2004;89: 2963-2972

- -

Fructose Intake Increases Plasma

Triglycerides More than Glucose Intake

Copyright ©2004 The Endocrine Society

Teff, K. L. et al. J Clin Endocrinol Metab 2004;89: 2963 -2972

• Assessed associations with fructose-

containing sugar-sweetened beverages in 427 containing sugar-sweetened beverages in 427

adults with biopsy proven nonalcoholic fatty

liver disease

• Daily vs no intake was associated with 2.6

times the odds of having higher histologic

grades of liver fibrosis (p=.004)

Brunt, Vos et al, 2010

Sugar-Sweetened Beverage Consumption

High glycemic load

Postprandial hyperglycemia & hyperinsulinemia

Energy in liquid form

Displacement of more satiating foods

Passive calorie overconsumption

Increased hunger

Alteration of taste preferences

Sugar

Increased intake of sugary foods; decreased intake of

vegetables, fruits, etc

Incomplete calorie

compensation

Fructose

overconsumptionwhen drinking to

satisfy thirst

Increased energy intake

Obesity

Metabolic Syndrome(low HDLC, high triglyceride, hypertension, hyperglycemia

coagulopathy, chronic inflammation)

Diabetes CHD

Lower intake of fiber micronutrients,

antioxidants and other phytochemicals

Dental caries

Insulin resistance

B-cell dysfunction

Hyperuricemia

Gout