Consumption of Sugar /Non-Sugar Sweetened Drinks on Heart Disease

TAKE-HOME MESSAGE — From Practice Update Monthly Top Ten in Cardiology

• In this large analysis of data from two large studies, the authors evaluated the association between sugar-sweetened beverages (SSBs) or artificially sweetened beverages (ASBs) and mortality from causes such as cardiovascular disease (CVD) and cancer. SSBs had the higher association with mortality, with CVD mortality significantly greater than cancer mortality. In the highest beverage intake category, ASBs were also associated with increased CVD but not cancer mortality.
• The authors concluded that SSBs increase CVD mortality risk based on intake dose, and further studies are necessary to determine the true association between ASBs and CVD mortality.

Cardiology — My Commentary on the Article

I Would Like Just Water, Thank You

Sugar-sweetened beverages (SSBs) are associated with increased weight gain, diabetes, coronary heart disease, and stroke, but there is little information on how SSBs and artificially sweetened beverages (ASBs) affect mortality. Malik and colleagues have examined the effect of these drinks on mortality in the Nurses’ Health Study (NHS) and the Health Professionals Follow-Up Study (HPFS). The NHS was started in 1976 and included 121,700 women between the ages of 30 and 55 years. The HPFS was started in 1986 and included 51,529 men aged 40 to 75 years. These studies collected dietary data using food-frequency questionnaires in 1984 in the NHS and in 1986 in the HPFS and every 4 years thereafter.

Malik and colleagues demonstrate that total mortality increased with the consumption of SSBs from a reference intake of <1/month to 1–4/month (+1% mortality), 2–6/week (+6%), 1–2/day (+14%), >2/day (+21%) [P<.0001 for trend] even after adjusting for potentially confounding factors. The increased mortality was largely due to increased cardiovascular mortality, which increased 31% between the lowest and highest SSB groups (P<.0001). Cancer mortality also increased between these groups by 16% (P<.0004). Fruit juice was not considered a SSB.

ASBs were also associated with higher total and cardiovascular disease mortality but only in the highest intake group, and the increase was only 4% for total and 13% for cardiovascular mortality (P<.01 and .02, respectively). The association of ASBs with mortality was only noted in the female NHS cohort and not in the male HPFS group. Artificially sweetened beverages were not associated with cancer in either group.

Such observational studies, even when prospective, are always difficult to evaluate. Were the adjustments for confounders sufficient or were some confounders overlooked? Diet studies are especially difficult because they rely on participants accurately reporting their intake. This study has the potential for such problems. The authors note that SSB intake may simply reflect bad dietary or lifestyle habits, but adjusted for confounders appropriately. Also, the food questionnaires were validated, completed by health professionals, and appear to coincide with other physiologic data.

Consequently, this report provides the best data to date that SSBs are a potential health problem, and that their consumption should be discouraged. ASBs appear to be less of a health issue, and primarily in women, but these data require further examination to explain the different effect between the sexes.