Association of soft drink and 100% fruit juice consumption with all-cause mortality, cardiovascular diseases mortality, and cancer mortality: A systematic review and dose-response meta-analysis of prospective cohort studies

Health effects of drinking 100% juice: an umbrella review of systematic reviews with meta-analyses

CONTEXT

Low fruit and vegetable intakes are major modifiable determinants of disease. One hundred percent juice may facilitate intake and deliver essential nutrients and bioactive compounds. However, the position of 100% juice in healthy eating guidelines remains controversial due to its lower dietary fiber and higher free-sugar contents compared with whole fruits and vegetables.

OBJECTIVE

To conduct an umbrella review of systematic literature reviews with meta-analyses (MAs) to summarize the health benefits of drinking 100% fruit and/or vegetable juice.

DATA SOURCES

Four databases (Medline, The Cochrane Library, EMBASE, and CINAHL) were systematically searched for MAs of 100% juice and any health outcomes.

DATA ANALYSIS

Screening, quality, risk of bias, and content overlap tools were applied, and extracted data were narratively synthesized. No eligible studies for vegetable juice were found. Fifteen systematic literature reviews (51 primary MAs, 6 dose-response, and 87 subanalyses; 50-1200 mL/day; hours to years of duration) were included. Ten MAs (19.6%) reported health benefits (4 for blood pressure, 2 for vascular function, 3 for inflammation, 1 for stroke mortality), 3 MAs (5.9%) reported adverse risks (1 each for cardiovascular disease mortality, prostate cancer, type 2 diabetes risk), while most (74.5%) reported no effect (blood lipids, body composition, liver function, metabolic health, cancers, and inflammation). Risks were limited to cohort studies and benefits were found in both cohort and intervention studies.

CONCLUSION

The findings collate evidence showing some potential health benefits associated with 100% juice consumption, with fewer potential risks. The balance of evidence does not support the exclusion of 100% juice from food-based guides to healthy eating, although caution may be warranted in certain groups or individuals, and the body of evidence is not yet conclusive.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022380588.

Association between sugar-sweetened beverages and pure fruit juice with risk of six cardiovascular diseases: a Mendelian randomization study

BACKGROUND

In observational and prospective cohort studies, intake of sugar-sweetened beverages (SSBs) and pure fruit juice (PFJ) has been associated with cardiovascular disease (CVD). Still, the causality of the connection has not yet been determined. Our objective was to uncover the relationship between SSBs/PFJ and CVD.

METHODS

Genetically predicted causal associations between SSBs/PFJ (obtained in a published genome-wide association study) and six common CVDs (atrial fibrillation (AF), angina, heart failure (HF), acute myocardial infarction, hypertension, and coronary atherosclerosis) were assessed using MR analytic modeling. The primary analysis method utilized was the inverse variance weighted (IVW) method, complemented by additional methods such as the weighted median method, MR Egger regression, Cochran's Q test, MR pleiotropy residual, funnel plot, Bonferroni correction, and others for MR analysis. To ensure the robustness of the findings, F-values were calculated as a complementary test to set looser thresholds for exposing genetic instrumental variables (P < 1e-5).

RESULTS

The results of MR analysis suggested genetically causal associations between SSBs and AF (odds ratio (OR): 1.023; 95% confidence interval (CI) 1.007-1.038; P = 0.0039) as well as between PFJ and angina (OR: 0.968; 95% CI, 0.943-0.993; P = 0.0138) there was genetic causality. However, MR analysis showed no causal association between SSBs/PFJ and other CVD risks.

CONCLUSION

This study suggests that there may be a potential causal relationship between SSBs intake and AF and a causal negative association between PFJ intake and angina.

Beverages - a scoping review for Nordic Nutrition Recommendations 2023

Background: Coffee, tea, sugar-sweetened beverages (SSBs), and low- and no-calorie sweetened beverages (LNCSBs) are generally frequently consumed in the Nordic and Baltic countries. These beverages have also been related to potential health effects. This scoping review describes the evidence for the role of coffee, tea, SSBs, and LNCSBs for health-related outcomes as a basis for setting and updating food-based dietary guidelines. We used evidence from several qualified systematic reviews (i.e. World Cancer Research Fund, US Dietary Guidelines Advisory Committee, European Food Safety Authority, and World Health Organization) and performed a search for additional systematic reviews. The evidence suggests that moderate coffee and tea consumption do not have long-term adverse health effects. The long-term favorable effects of coffee consumption are related to reduced risk of endometrial and liver cancer, type 2 diabetes, and cardiovascular deaths. However, results from randomized controlled trials (RCTs) suggest that coffee brews that are rich in diterpenes, such as boiled coffee, increase serum cholesterol concentrations. High caffeine intake in pregnancy is associated with higher risk of pregnancy loss, preterm birth, and low birth weight. High consumption of SSBs has been associated with increased risk of obesity, type 2 diabetes, hypertension, and cardiovascular disease, based on data from RCTs and prospective cohort studies. The consumption of LNCSBs may result in a small reduction in body weight in adults, likely mediated through the effect of reduced energy intake, but has neutral effects on other cardiometabolic risk markers using evidence from RCTs. However, evidence from observational studies indicates increased risk of cardiometabolic diseases among high LNCSB consumers. In conclusion, current evidence suggests that moderate coffee and tea consumption have no long-term adverse health effects. The evidence of beneficial effects of coffee consumption on liver and endometrial cancer risk, and some cardiovascular outcomes, comes from observational studies. High consumption of boiled coffee should be avoided due to negative effect on lipid profile. Pregnant women should not exceed the recommended daily dose of caffeine intake of 200 mg set by the European Food Safety Authority as a safe level for the fetus. High consumption of SSBs has consistently been associated with adverse health effects, which is mainly due to excess energy intake, and should be limited. The conflicting results from RCTs and observational studies regarding LNCSBs may be due to revere causation and should be explored further.

Artificially sweetened beverages consumption and risk of obesity-related cancers: a wide-angled Mendelian randomization study

Background

The impact of artificially sweetened beverages (ASBs) consumption on obesity-related cancers (ORCs) risk remains controversial. To address this challenging issue, this study employed wide-angle mendelian randomization (MR) analyses to explore the genetic causality between ASB consumption and the risk of ORCs, thereby effectively minimizing the impact of external confounders.

Methods

We conducted a suite of analyses encompassing univariable, multivariable, and two-step MR to evaluate causal associations between ASB consumption (samples = 85,852) and risk of ORCs (total samples = 2,974,770) using summary statistics from genome-wide association studies (GWAS). Total, direct, and intermediary effects were derived by performing inverse-variance weighted (IVW), MR-Egger, weighted mode, weighted median, and lasso method. Additionally, we performed an extensive range of sensitivity analyses to counteract the potential effects of confounders, heterogeneity, and pleiotropy, enhancing the robustness and reliability of the findings.

Results

Genetically predicted ASB consumption was positively associated with the risk of colorectal cancer (CRC, p = 0.011; OR: 6.879; 95% CI: 1.551, 30.512 by IVW) and breast cancer (p = 0.022; OR: 3.881; 95% CI: 2.023, 9.776 by IVW). Multivariable analysis yielded similar results. The results of the two-step MR unveiled that body mass index (BMI) assumes a pivotal role in mediating the association between ASB consumption and CRC risk (intermediary effect = 0.068, p = 0.024).

Conclusion

No causal connection exists between ASB consumption and the majority of ORCs, in addition to CRC and breast cancer. Additionally, our findings suggest that BMI might be a potential mediator in the association between ASB consumption and CRC.

Fruit juice - a scoping review for Nordic Nutrition Recommendations 2023

Fruit juice has a similar nutrient content as whole fruit and may in this respect be part of a healthy diet. However, a lower amount or lack of fibre and a higher concentration of sugars and energy could also contribute to less satiation and increase the risk of excess energy intake. The aim of this scoping review is to describe the overall evidence for the role of fruit juice as a basis for setting and updating food-based dietary guidelines in the Nordic Nutrition Recommendations 2023. PubMed was searched for systematic reviews and meta-analyses and evidence was extracted on relevant health outcomes. Current available evidence indicates that low to moderate consumption of fruit juice is not associated with an apparent risk of chronic diseases and may have protective effects on cardiovascular disease. The association between the intake of fruit juice and weight gain remains unclear and might be of concern for some groups of people. Overall, the evidence regarding health effects of fruit juice is limited.

Association of a healthy beverage score with total mortality in the adult population of Spain: A nationwide cohort study

BACKGROUND

Despite the substantial evidence of the relationship between diet and mortality, the role of beverage consumption patterns is not well known. The aim of this study was to assess the association of the adherence to a Healthy Beverage Score (HBS) and all-cause mortality in a representative sample of the Spanish adult population.

METHODS AND FINDINGS

We conducted an observational cohort study using data from the Study on Nutrition and Cardiovascular Risk in Spain (ENRICA), which included 12,161 community-dwelling individuals aged ≥18 years recruited in 2008 to 2010 and followed until January 2022. At baseline, food consumption was collected using a validated diet history. The HBS consists of 7 items, each of which is scored from 1 to 4 (highest adherence). The HBS ranges from 7 to 28 points with a higher score representing a healthier pattern. Adherence was assigned as a higher consumption of low-fat milk, and coffee and tea, a lower consumption of whole-fat milk, no consumption of fruit juice, artificially sweetened beverages, or sugar-sweetened beverages, and no or moderate consumption of alcohol. Total mortality was ascertained by linkage to the Spanish National Death Index. Statistical analyses were performed with Cox models and adjusted for the main confounders, including sociodemographic, lifestyle, dietary variables, and morbidity. After a mean follow-up of 12.5 years (SD: 1.7; range: 0.5 to 12.9), a total of 967 deaths occurred. For all-cause mortality, the fully adjusted hazard ratio (HR) for the highest versus lowest sex-specific quartiles of HBS was 0.72 (95% confidence interval [0.57, 0.91], p linear-trend = 0.015), corresponding to an 8.3% reduction in the absolute risk of death. A linear relationship between the risk of death and the adherence to the HBS was observed using restricted cubic splines. The results were robust to sensitivity analyses. The main limitation was that repeated measurements on beverage consumption were not available and beverage consumption could have changed during follow-up.

CONCLUSIONS

In this study, we observed that higher adherence to the HBS was associated with lower total mortality. Adherence to a healthy beverage pattern could play a role in the prevention of premature mortality.

Sugar sweetened beverages, natural fruit juices, and cancer: what we know and what still needs to be assessed

Cancer is known as one of the leading causes of death in the world. In addition to early mortality, cancer is associated with disability in affected patients. Among environmental risk factors, special attention has been paid to the role of dietary factors. In recent decades, the consumption of sugar-sweetened beverages (SSBs) and natural fruit juices has increased. Several studies have assessed the effects of these beverages on human health and found that a higher intake of SSBs is associated with a greater risk of obesity, diabetes, cardiovascular diseases, hypertension, and non-alcoholic fatty liver disease. However, current evidence for cancer incidence and mortality is not conclusive. In the current review, we concluded that SSBs intake might be positively associated with cancer incidence/mortality through their increasing effects on obesity, inflammatory biomarkers, serum levels of insulin-like growth factor-I (IGF-I), and advanced glycation end-products. Such a positive association was also seen for natural fruit juices. However, types of natural fruit juices were not considered in most previous studies. In addition, some types of cancer including brain, lung, and renal cancers were not assessed in relation to SSBs and natural fruit juices. Therefore, further studies are needed in this regard.

Impact of Fruit and Fruit Juice on Death and Disease Incidence: A Sex-Specific Longitudinal Analysis of 18 603 Adults

BACKGROUND

The health benefits of fruits are well established, but fruit juice has been more controversial. Fruit and juice are often ingested with other foods, which prompted our investigation to determine whether fruit consumed as juice may negate the beneficial effects of consuming whole fruit in people with cardiovascular disease.

METHODS AND RESULTS

We retrospectively analyzed data from a population-based study in Australia (the 45 and Up Study) linked with hospitalization and mortality data up to September 2018. Kaplan-Meier survival estimates and Cox proportional hazards models were used to examine effects of fruit, fruit juice, and the combination of fruit and fruit juice in relation to death and disease incidence among men and women living with cardiovascular disease. A total of 7308 deaths occurred among 18 603 participants diagnosed with cardiovascular disease over a 13-year follow-up. After multivariable adjustment, inadequate fruit intake (hazard ratio [HR], 1.12 [95% CI, 1.01-1.24]) and high fruit juice intake (HR, 1.26 [95% CI, 1.12-1.41]) predicted all-cause mortality in women. Also, high fruit juice intake plus either adequate fruit intake (HR, 1.18 [95% CI, 1.02-1.37]) or inadequate fruit intake (HR, 1.43 [95% CI, 1.21-1.69]) predicted mortality in women. No relationships were found in men after multivariable adjustments. Also, we found no prognostic value for fruit and fruit juice intake on disease incidence.

CONCLUSIONS

In adults with cardiovascular disease, we found that fruit juice (in combination with adequate or inadequate fruit intake) predicted mortality in women but not in men. These effects became less clear when focusing on disease incidence.

White rice consumption and risk of cardiometabolic and cancer outcomes: A systematic review and dose-response meta-analysis of prospective cohort studies

White rice is the food more than half of the world's population depends on. White rice intake can significantly increase the glycemic load of consumers and bring some adverse health effects. However, the quality of evidence implicating white rice in adverse health outcomes remains unclear. To evaluate the association between white rice consumption and the risk of cardiometabolic and cancer outcomes, a systematic review and dose-response meta-analysis of the relevant publications were performed. Twenty-three articles including 28 unique prospective cohorts with 1,527,198 participants proved eligible after a comprehensive search in four databases. For the risk of type 2 diabetes mellitus (T2DM), the pooled RR was 1.18 (16 more per 1000 persons) for comparing the highest with the lowest category of white rice intake, with moderate certainty evidence. Females presented a higher risk (23 more per 1000 persons) in subgroup analysis. And every additional 150 grams of white rice intake per day was associated with a 6% greater risk of T2DM (5 more per 1000 persons) with a linear positive trend. We found no significant associations between white rice intake and risk of cardiovascular diseases (CVD), CVD mortality, cancer, and metabolic syndrome. In conclusion, moderate certainty evidence demonstrated that white rice intake was associated with T2DM risk, with a linear positive trend. However, low to very low certainty of evidence suggested that no substantial associations were found between white rice intake and other cardiometabolic and cancer outcomes. More cohorts are needed to strength the evidence body.

An integrative analytical framework to identify healthy, impactful, and equitable foods: a case study on 100% orange juice

To identify healthy, impactful, and equitable foods, we combined health scores from six diverse nutrient profiling systems (NPS) into a meta-framework (meta-NPS) and paired this with dietary guideline adherence assessment via multilevel regression and poststratification. In a case-study format, a commonly debated beverage formulation - 100% orange juice (OJ) - was chosen to showcase the utility and depth of our framework, systematically scoring high across multiple food systems (i.e. a Meta-Score percentile = 93rd and Stability percentile = 75th) and leading to an expected increase of US dietary fruit guideline adherence by ∼10%. Moreover, the increased adherence varies across the 300 sociodemographic strata, with the benefit patterns being sensitive to absolute or relative quantification of the difference of adherence affected by OJ. In sum, the adaptable, integrative framework we established deepens the science of nutrient profiling and dietary guideline adherence assessment while shedding light on the nuances of defining equitable health effects.

Sweeteners and the Gut Microbiome: Effects on Gastrointestinal Cancers

Worldwide, the demand for natural and synthetic sweeteners in the food industry as an alternative to refined sugar is increasing. This has prompted more research to be conducted to estimate its safety and effects on health. The gut microbiome is critical in metabolizing selected sweeteners which might affect overall health. Recently, more studies have evaluated the relationship between sweeteners and the gut microbiome. This review summarizes the current knowledge regarding the role played by the gut microbiome in metabolizing selected sweeteners. It also addresses the influence of the five selected sweeteners and their metabolites on GI cancer-related pathways. Overall, the observed positive effects of sweetener consumption on GI cancer pathways, such as apoptosis and cell cycle arrest, require further investigation in order to understand the underlying mechanism.

Associations of free sugars from solid and liquid sources with cardiovascular disease: a retrospective cohort analysis

BACKGROUND

The World Health Organization recommends a 10% total energy (TE%) limit for free sugars (i.e., added sugars and naturally occurring sugars in fruit juice, honey, and syrups) based on evidence linking higher intakes with overweight and dental caries. Evidence for cardiovascular disease (CVD) is limited. Impacts may differ by sex, age group, and solid vs. liquid sources; liquids may stimulate more adverse CVD profiles (due to their rapid absorption in the body along along with triggering less satiety). We examined associations of consuming total free sugars ≥ 10 TE% with CVD within four sex and age-defined groups. Given roughly equal free sugar intakes from solid and liquid sources, we also evaluated source-specific associations of free sugars ≥ 5 TE% thresholds.

METHODS

In this retrospective cohort study, we estimated free sugars from 24-h dietary recall (Canadian Community Health Survey, 2004-2005) in relationship to nonfatal and fatal CVD (Discharge Abstract and Canadian Mortality Databases, 2004-2017; International Disease Classification-10 codes for ischemic heart disease and stroke) through multivariable Cox proportional hazards models adjusted for overweight/obesity, health behaviours, dietary factors, and food insecurity. We conducted analyses in separate models for men 55 to 75 years, women 55 to 75 years, men 35 to 55 years, and women 35 to 55 years. We dichotomized total free sugars at 10 TE% and source-specific free sugars at 5 TE%.

RESULTS

Men 55 to 75 years of age had 34% higher CVD hazards with intakes of free sugars from solid sources ≥ 5 TE% vs. below (adjusted HR 1.34, 95% CI 1.05- 1.70). The other three age and sex-specific groups did not demonstrate conclusive associations with CVD.

CONCLUSIONS

Our findings suggest that from a CVD prevention standpoint in men 55 to 75 years of age, there may be benefits from consuming less than 5 TE% as free sugars from solid sources.

Association of beverage consumption with subclinical atherosclerosis in a Spanish working population

Beverages play a substantial role meeting water, calorie, and nutrient requirements; however, they are presented as being major contributors to the current obesity epidemic. Although, the relationship between beverage consumption and metabolic risk factors for cardiovascular disease (CVD) in adults has been frequently studied, its association with subclinical atherosclerosis is of increased interest. We studied the association of beverage consumption with the presence of peripheral subclinical atherosclerosis among Spanish workers. We performed a cross-sectional study of 2089 middle-aged males, with a mean age of 50.9 (SD 3.9), and without CVD, carried out in the Aragon Workers' Health Study (AWHS). A food frequency questionnaire was used to measure beverage consumption of low-fat milk, coffee and tea (unsweetened), whole-fat milk, sugar-sweetened beverages, bottled fruit juice, artificially-sweetened beverages and 100% fruit juice. Atherosclerotic plaques were measured by ultrasound (in carotid arteries, and in femoral arteries). Atherosclerotic plaque was defined as a focal structure protruding ≥ 0.5 mm into the lumen, or reaching a thickness ≥ 50% of the surrounding intima-media thickness. As statistical analysis, we use logistic regression models, simultaneously adjusted for all beverage groups. As results, unsweetened coffee was the beverage most associated with peripheral subclinical atherosclerosis with an odds ratio (OR) of 1.25 (1.10-1.41), and 1.23 (1.09-1.40) 100g/day] for carotid, and femoral territories respectively. Moreover, subclinical atherosclerosis was positively associated with whole-fat milk [OR 1.10 (1.02-1.18) 100 g/day] in the femoral territory. The association was protective for low-fat milk in the carotid territory [OR 0.93 (0.88-0.99) 100g/day]. There was also a protective association with bottled fruit juices in the femoral territory [0.84 (0.74-0.94) 100g/day]. Our results suggest a detrimental association with the consumption of coffee, as well as with whole-fat milk and the presence of subclinical atherosclerosis. Therefore, an element of prudence excluding water and low-fat milk, must be applied when recommending beverage consumption.

Beverage consumption and mortality among adults with type 2 diabetes: prospective cohort study

OBJECTIVE

To investigate the intake of specific types of beverages in relation to mortality and cardiovascular disease (CVD) outcomes among adults with type 2 diabetes.

DESIGN

Prospective cohort study.

SETTING

Health professionals in the United States.

PARTICIPANTS

15 486 men and women with a diagnosis of type 2 diabetes at baseline and during follow-up (Nurses' Health Study: 1980-2018; and Health Professionals Follow-Up Study: 1986-2018). Beverage consumption was assessed using a validated food frequency questionnaire and updated every two to four years.

MAIN OUTCOME MEASURES

The main outcome was all cause mortality. Secondary outcomes were CVD incidence and mortality.

RESULTS

During an average of 18.5 years of follow-up, 3447 (22.3%) participants with incident CVD and 7638 (49.3%) deaths were documented. After multivariable adjustment, when comparing the categories of lowest intake of beverages with the highest intake, the pooled hazard ratios for all cause mortality were 1.20 (95% confidence interval 1.04 to 1.37) for sugar sweetened beverages (SSBs), 0.96 (0.86 to 1.07) for artificially sweetened beverages (ASBs), 0.98 (0.90 to 1.06) for fruit juice, 0.74 (0.63 to 0.86) for coffee, 0.79 (0.71 to 0.89) for tea, 0.77 (0.70 to 0.85) for plain water, 0.88 (0.80 to 0.96) for low fat milk, and 1.20 (0.99 to 1.44) for full fat milk. Similar associations were observed between the individual beverages and CVD incidence and mortality. In particular, SSB intake was associated with a higher risk of incident CVD (hazard ratio 1.25, 95% confidence interval 1.03 to 1.51) and CVD mortality (1.29, 1.02 to 1.63), whereas significant inverse associations were observed between intake of coffee and low fat milk and CVD incidence. Additionally, compared with those who did not change their consumption of coffee in the period after a diabetes diagnosis, a lower all cause mortality was observed in those who increased their consumption of coffee. A similar pattern of association with all cause mortality was also observed for tea, and low fat milk. Replacing SSBs with ABSs was significantly associated with lower all cause mortality and CVD mortality, and replacing SSBs, ASBs, fruit juice, or full fat milk with coffee, tea, or plain water was consistently associated with lower all cause mortality.

CONCLUSIONS

Individual beverages showed divergent associations with all cause mortality and CVD outcomes among adults with type 2 diabetes. Higher intake of SSBs was associated with higher all cause mortality and CVD incidence and mortality, whereas intakes of coffee, tea, plain water, and low fat milk were inversely associated with all cause mortality. These findings emphasize the potential role of healthy choices of beverages in managing the risk of CVD and premature death overall in adults with type 2 diabetes.

Dietary sugar consumption and health: umbrella review

OBJECTIVE

To evaluate the quality of evidence, potential biases, and validity of all available studies on dietary sugar consumption and health outcomes.

DESIGN

Umbrella review of existing meta-analyses.

DATA SOURCES

PubMed, Embase, Web of Science, Cochrane Database of Systematic Reviews, and hand searching of reference lists.

INCLUSION CRITERIA

Systematic reviews and meta-analyses of randomised controlled trials, cohort studies, case-control studies, or cross sectional studies that evaluated the effect of dietary sugar consumption on any health outcomes in humans free from acute or chronic diseases.

RESULTS

The search identified 73 meta-analyses and 83 health outcomes from 8601 unique articles, including 74 unique outcomes in meta-analyses of observational studies and nine unique outcomes in meta-analyses of randomised controlled trials. Significant harmful associations between dietary sugar consumption and 18 endocrine/metabolic outcomes, 10 cardiovascular outcomes, seven cancer outcomes, and 10 other outcomes (neuropsychiatric, dental, hepatic, osteal, and allergic) were detected. Moderate quality evidence suggested that the highest versus lowest dietary sugar consumption was associated with increased body weight (sugar sweetened beverages) (class IV evidence) and ectopic fatty accumulation (added sugars) (class IV evidence). Low quality evidence indicated that each serving/week increment of sugar sweetened beverage consumption was associated with a 4% higher risk of gout (class III evidence) and each 250 mL/day increment of sugar sweetened beverage consumption was associated with a 17% and 4% higher risk of coronary heart disease (class II evidence) and all cause mortality (class III evidence), respectively. In addition, low quality evidence suggested that every 25 g/day increment of fructose consumption was associated with a 22% higher risk of pancreatic cancer (class III evidence).

CONCLUSIONS

High dietary sugar consumption is generally more harmful than beneficial for health, especially in cardiometabolic disease. Reducing the consumption of free sugars or added sugars to below 25 g/day (approximately 6 teaspoons/day) and limiting the consumption of sugar sweetened beverages to less than one serving/week (approximately 200-355 mL/week) are recommended to reduce the adverse effect of sugars on health.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022300982.

Consumption of sugar sweetened beverages, artificially sweetened beverages and fruit juices and risk of type 2 diabetes, hypertension, cardiovascular disease, and mortality: A meta-analysis

Introduction

Sugar-sweetened beverage (SSB) intake is associated with an increased risk of cardiometabolic diseases. However, evidence regarding associations of artificially sweetened beverages (ASBs) and fruit juices with cardiometabolic diseases is mixed. In this study, we aimed to investigate the association between the SSB, ASB and fruit juice consumption with the incidence of cardiometabolic conditions and mortality.

Methods

Relevant prospective studies were identified by searching PubMed, Web of Science, Embase, and Cochrane Library until December 2022 without language restrictions. The pooled relative risk (RR) and 95% confidence intervals (CIs) were estimated for the association of SSBs, ASBs, and fruit juices with the risk of type 2 diabetes (T2D), cardiovascular disease (CVD), and mortality by using random-effect models.

Results

A total of 72 articles were included in this meta-analysis study. Significantly positive associations were observed between the consumption of individual beverages and T2D risk (RR: 1.27; 95% CI: 1.17, 1.38 for SSBs; RR: 1.32; 95% CI: 1.11, 1.56 for ASBs; and RR:0.98; 95% CI: 0.93, 1.03 for fruit juices). Moreover, our findings showed that intakes of SSBs and ASBs were significantly associated with risk of hypertension, stroke, and all-cause mortality (RR ranging from 1.08 to 1.54; all p &lt; 0.05). A dose-response meta-analysis showed monotonic associations between SSB intake and hypertension, T2D, coronary heart disease (CHD), stroke and mortality, and the linear association was only significant between ASB consumption and hypertension risk. Higher SSB and ASB consumptions were associated with a greater risk of developing cardiometabolic diseases and mortality. Fruit juice intake was associated with a higher risk of T2D.

Conclusion

Therefore, our findings suggest that neither ASBs nor fruit juices could be considered as healthier beverages alternative to SSBs for achieving improved health.

Systematic Review Registration: [PROSPERO], identifier [No. CRD42022307003].

The health and economic burden associated with sugar-sweetened beverage consumption in Trinidad and Tobago

BACKGROUND

In Trinidad and Tobago, non-communicable diseases (NCDs) are the leading cause of death. Unhealthy diet is one modifiable NCD risk factor, which contributes to the NCD burden. The consumption of sugar-sweetened beverages (SSBs) has been associated with an increased risk of NCDs.

AIM

The aim of this paper is to estimate the burden of disease and economic costs associated with the consumption of SSBs in Trinidad and Tobago as evidence to support the implementation of health and fiscal policies on SSB consumption.

METHODS

The results of this study were obtained through the use of a mathematical model which used a comparative risk assessment approach to estimate the health and economic burden associated with SSB intake, by sex and age.

RESULTS

Estimates for one year showed that SSB consumption was associated with approximately 15,000 cases of overweight and obesity in adults and 11,700 cases in children, 28% of all the cases of diabetes and overall, an estimated 387 deaths and 9000 years of healthy life were lost due to premature death and disability. Approximately US$23.1 million was spent in the public healthcare system to treat diseases associated with consumption of sugary beverages.

CONCLUSIONS

The consumption of SSBs is associated with increases in diseases, deaths and rising healthcare costs in Trinidad and Tobago. It is hoped that the results of this study will provide an added rationale and impetus for the implementation of policies to reduce the consumption of SSBs.

Advertising expenditures across media on food and beverage products heavily advertised on youth-appealing television stations in Canada

This research estimated and characterized advertising expenditures on food products heavily advertised on youth-appealing television stations in Canada in 2019 overall, by media, by food category, and compared expenditures in two policy environments (Quebec and the rest of Canada, excluding the territories) and on "healthier" versus "less healthy" products. Advertising expenditure estimates for 57 selected food categories promoted on television, radio, out-of-home media, print media, and popular websites were licensed from Numerator. Sixty-one products or brands were identified as heavily advertised on youth-appealing stations and classified as "healthier" or "less healthy" based on a nutrient profile model proposed by Health Canada. Total expenditures and expenditures per adolescent capita were calculated. Approximately, $110.9 million was spent advertising food products heavily advertised to adolescents in Canada in 2019, with television accounting for 77% of total expenditures and fast food restaurants accounting for 51%. Most expenditures (77%; $80.6 million) were devoted to advertising "less healthy" products. In Quebec, advertising expenditures on examined products were 23% lower per capita ($45.15/capita) compared to the rest of Canada ($58.44/capita). Advertising expenditures in Quebec were lower for energy drinks (-47%; -$0.80/capita) and candy and chocolate (-41%; -$1.00/capita) and higher for yogurt (+85%; +$1.22/capita) and portable snacks (+25%; +$0.15/capita). Quebec's restriction of commercial advertising directed to children under 13 may explain lower per capita advertising expenditures on some "less healthy" foods heavily advertised to adolescents in Quebec. Nevertheless, this spending remains high in Quebec and nationally. Continued monitoring of these expenditures is warranted.

Association between soft drink consumption types and risk of lung cancer and all-cancer: A prospective study of PLCO data

Diet/sugar-free soft drinks are considered to be healthier than regular soft drinks. However, few studies have examined the relationship between the types of soft drinks (regular and diet/sugar-free) and lung cancer (LC)/all-cancer (AC) risk. In this study, we comprehensively assessed the influence of the type of soft drink consumption on LC/AC risk based on the Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial. Multivariable Cox proportional hazards and competing risks Fine-Gray regression models adjusted for relevant confounders were used to estimate hazard ratios (HRs) and subdistribution HRs for different types of soft drink consumption. In the PLCO population, female subgroup, and the ever/current smoker subgroup, consumption of both regular and diet soft drinks was associated with a significantly reduced risk of LC compared with no soft drinks at all. For the non-lung cancer (NLC) risk, consumption of only diet soft drinks had a significant positive association for the total population and female subgroup. Based on our findings, it was suggested that partial replacement of regular soft drinks with diet soft drinks might be beneficial to LC prevention, especially for females and ever/current smokers. Additionally, completely replacing regular soft drinks with diet soft drinks might be detrimental to NLC prevention, especially for females.

Added Sugar, Sugar-Sweetened Beverages, and Artificially Sweetened Beverages and Risk of Cardiovascular Disease: Findings from the Women’s Health Initiative and a Network Meta-Analysis of Prospective Studies

Much remains unknown about the role of added sugar in relation to cardiovascular disease (CVD) and the relative contributions of sugar-sweetened beverages (SSB) or artificially sweetened beverages (ASB) to CVD risk. Among the 109,034 women who participated in Women’s Health Initiative, we assessed average intakes of added sugar, SSB and ASB, and conducted Cox regression to estimate the hazard ratios (HRs) and their 95% confidence intervals for CVD risk. The consistency of findings was compared to a network meta-analysis of all available cohorts. During an average of 17.4 years of follow-up, 11,597 cases of total CVD (nonfatal myocardial infarction, coronary heart disease (CHD) death, stroke, coronary revascularization, and/or incident heart failure) were confirmed. Added sugar as % energy intake daily (%EAS) at ≥15.0% was positively associated with total CVD (HR = 1.08 [1.01, 1.15]) and CHD (HR = 1.20 [1.09, 1.32]). There was also a higher risk of total CVD associated with ≥1 serving of SSB intake per day (HR = 1.29 [1.17, 1.42]), CHD (1.35 [1.16, 1.57]), and total stroke (1.30 [1.10, 1.53]). Similarly, ASB intake was associated with an increased risk of CVD (1.14 [1.03, 1.26]) and stroke (1.24 [1.04, 1.48]). According to the network meta-analysis, there was a large amount of heterogeneity across studies, showing no consistent pattern implicating added sugar, ASB, or SSB in CVD outcomes. A diet containing %EAS ≥15.0% and consuming ≥1 serving of SSB or ASB may be associated with a higher CVD incidence. The relative contribution of added sugar, SSB, and ASB to CVD risk warrants further investigation.

Can Artificial Sweeteners Increase the Risk of Cancer Incidence and Mortality: Evidence from Prospective Studies

Cancer has become a major challenge in the global disease burden. Artificial sweeteners are a class of chemical compounds that are used as food and beverage addition agent to replace sugar. However, the health effects of consuming artificial sweeteners are still unclear. This meta-analysis was performed to evaluate the role of artificial sweeteners on cancer. The databases PubMed, Cochrane Library, MEDLINE, Web of Science and EMBASE were searched up until July 2022. A Newcastle−Ottawa scale (NOS) was used to estimate the study quality. A total of 25 observational studies were included with a total of 3,739,775 subjects. The intake of artificial sweeteners had no apparent association with overall cancer incidence and mortality. However, in Europe, artificial sweeteners’ intake could increase the risk of cancer incidence (HR/RR = 1.07, 95% CI = [1.02, 1.12], I2 = 25.8%, P = 0.223), which appears to be related to a shift in nutritional behaviors in the countries. Significant results were also observed in subgroups with aspartame and a mixed intake of artificial sweeteners. Moreover, higher risk was observed for artificial sweeteners intake in all-cause mortality (HR/RR =1.13, 95% CI = [1.03, 1.25], I2 = 79.7%, p < 0.001) and a J-shaped association between them was found. More data from well-conducted studies and clinical trials are required.

A Prospective Study of Fruit Juice Consumption and the Risk of Overall and Cardiovascular Disease Mortality

There is little evidence for the association between fruit juice, especially 100% fruit juice, and mortality risk. In addition, whether 100% fruit juice can be a healthy alternative to whole fruit remains uncertain. This prospective study utilized the data from the US National Health and Nutrition Examination Survey (NHANES) from 1999 to 2014. After a median follow-up of 7.8 years, 4904 deaths among 40,074 participants aged 18 years or older were documented. Compared to non-consumption, daily consumption of 250 g or more of 100% fruit juice was associated with higher overall mortality (hazard ratio (HR) = 1.30, 95% confidence interval (CI): 1.11–1.52) and mortality from heart disease (HR = 1.49, 95 CI: 1.01–2.21). A similar pattern was observed for total fruit juice, with HRs of 1.28 (95% CI: 1.09–1.49) for overall mortality and 1.48 (95% CI: 1.01–2.17) for heart disease mortality. Replacing 5% of energy from whole fruit with 100% or total fruit juice was associated with a 9% (95% CI: 2–16%) and 8% (95% CI: 1–15%) increased mortality risk, respectively. Our findings suggest that both total and 100% fruit juice could be associated with high mortality risk, and need to be validated in well-designed studies given the potential misclassification of diet and death reasons.

Sweetened beverage consumption and risk of cardiovascular mortality: A systematic review and meta-analysis

BACKGROUND AND AIMS

Several studies have reported the association of sweetened beverages (SB) with cardiovascular disease. However, the relationship between SB and cardiovascular mortality has not been clearly established. This systematic review and meta-analysis investigated the association between SB consumption and cardiovascular mortality.

METHODS

PubMed/MEDLINE, Web of Science, and Embase were systematically searched up to July 31, 2021, for prospective cohort studies investigating this association in adults. Pooled relative risks (RRs) and 95% confidence intervals (CIs) were used to assess the strength of association between SB: sugar-sweetened beverages (SSB)/artificial-sweetened beverages (ASB) exposure and cardiovascular mortality.

RESULTS

A total of eight cohort studies comprising 1.2 million participants exposed to SB, reported 15,831 (1.2%) cases of cardiovascular mortality with a median follow-up of 12.2 years. Consuming at least one glass (250 ml) of SB per day (RR: 1.06; 95% CI: 1.00-1.12, P < 0.001) or ≥2 glasses per day (RR: 1.24; 95% CI: 1.16-1.31, P < 0.001) was significantly associated with increased risk of cardiovascular mortality. SSB and ASB intake of ≥2 glasses per day increased the risk of cardiovascular mortality by 21% (RR:1.21, 95% CI: 1.09-1.33, P < 0.001) and 33% (RR: 1.33, 95% CI: 1.12-1.55, P < 0.001), respectively.

CONCLUSIONS

Our findings reveal that high SSB and ASB consumption are associated with an increased risk of cardiovascular mortality. Policymakers and public health practitioners should work on multisectoral strategies to reduce the consumption of sweetened beverages around the world and among all population groups.

The Effects of Dietary Pattern on Metabolic Syndrome in Jiangsu Province of China: Based on a Nutrition and Diet Investigation Project in Jiangsu Province

Metabolic syndrome, a complex group of metabolic disorders of energy use and storage, is considered as an important determinant risk factor for many cardiovascular diseases. This study aimed to examine the association between metabolic syndrome (MetS) and dietary pattern among adults in Jiangsu Province of China. Data were from three rounds of cross–sectional nutrition and diet investigation projects in Jiangsu Province of China, which were conducted in 2002, 2007, and 2014 by Jiangsu Provincial Center for Disease Control and Prevention. A total of 13,944 participants with complete food frequency questionnaire (FFQ) were eventually included in this study after further data screening. The 2009 Joint Interim Statement for China was used to define metabolic syndrome. Three distinct dietary patterns were identified by factor analysis: the modern dietary pattern (rich in pork, poultry, vegetables, seafood, pastry food, other animal meats, fruits, milk and its products, soft drink, whole grains, nuts, and seeds, but low in wheat), vegetable oils/condiments/soy products dietary pattern (rich in vegetable oils, other condiments, salt, soy products, and fruits and low in dry legumes), and modern high–wheat dietary pattern (rich in wheat, tubers, fruits, and other animal meats, but low in rice). Higher intake of the modern dietary pattern and modern high–wheat dietary pattern were positively associated with metabolic syndrome in both unadjusted and adjusted models by genders, whereas higher intake of the vegetable oils/condiments/soy products dietary pattern had a negative relationship with metabolic syndrome in both unadjusted and adjusted models by genders (p < 0.05). Our study recommends reducing the consumption of animal meat products, especially processed meat products, and replacing animal oils with vegetable oils as the main supply of daily oils. Furthermore, more prospective and experimental studies are needed to confirm the relationship between dietary patterns and metabolic syndrome.

The Role of Diet, Alcohol, BMI, and Physical Activity in Cancer Mortality: Summary Findings of the EPIC Study

Evidence on the impact of diet, alcohol, body-mass index (BMI), and physical activity on mortality due to cancer and other cancer-related outcomes is still scarce. Herein, we reviewed the contribution of the European Prospective Investigation into Cancer and Nutrition (EPIC) study to the current state of the art on the role of these factors in cancer mortality. We identified 45 studies using a rapid systematic review methodology. Dietary factors associated with reduced cancer mortality included raw vegetable intake; dietary fiber intake; the Mediterranean diet; other dietary scores; other diet patterns including low meat eaters, vegetarians/vegans, or fish eaters; dietary intake (or biomarkers) of some vitamins (e.g., vitamin D, vitamin K2, or Vitamin C); and intake of lignans. Physical activity and following healthy lifestyle recommendations also reduced cancer mortality risk. In contrast, dietary factors associated with higher cancer mortality risk included poor diet quality, consumption of alcohol and soft drinks including juice, and, to a lesser extent, intake of some fatty acids. Excess weight and obesity also increased the risk of cancer mortality. The EPIC study holds valuable information on diet and lifestyle factors and offers a unique opportunity to identify key diet-related factors for cancer mortality prevention.