Sugars and risk of mortality in the NIH-AARP Diet and Health Study

Plant-based dietary patterns and mortality from all causes, cardiovascular disease, and cancer: The Multiethnic Cohort Study

BACKGROUND & AIMS

Plant-based dietary patterns have been associated with lower risk of cardiovascular disease (CVD), some cancers, and related mortality in U.S.

POPULATIONS

However, the quality of plant foods has rarely been considered in the association between plant-based diets and mortality, especially in a population with various racial and ethnic backgrounds. We investigated whether the adherence to plant-based dietary patterns and the healthiness of plant foods are associated with mortality from all causes, CVD, and cancer and evaluated how the association varies by race and ethnicity.

METHODS

A total of 144,729 African American, Japanese American, Latino, Native Hawaiian, and White men and women who participated in the Multiethnic Cohort Study (1993-2019) were included. Cox models were used to estimate HR and 95% CI of mortality from all causes, CVD, and cancer across quintiles of three plant-based diet scores: overall plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI).

RESULTS

Over an average 21 years of follow-up, we identified 65,087 deaths, including 18,663 from CVD and 16,171 from cancer. Comparing the highest versus lowest quintiles, greater scores of PDI and hPDI were associated with a lower risk of all-cause mortality in both men (HR = 0.85, 95% CI: 0.82-0.89 for PDI; HR = 0.88, 95% CI: 0.85-0.91 for hPDI; both P for trend <0.0001) and women (HR = 0.89, 95% CI: 0.86-0.93 for PDI; HR = 0.86, 95% CI: 0.83-0.89 for hPDI; both P for trend <0.0001). An increased risk of all-cause mortality with uPDI was observed only in women (HR = 1.11, 95% CI: 1.07-1.15, P for trend <0.0001; P for heterogeneity by sex = 0.019). A similar trend was shown for CVD mortality with a significant increase in risk with uPDI for both men and women. PDI was associated with a lower risk of cancer mortality in men (HR = 0.86, 95% CI: 0.80-0.92, P for trend <0.0001), while neither hPDI nor uPDI was associated in either sex. Compared with the other racial and ethnic groups within each sex, the association of uPDI with all-cause mortality was stronger in White men (P for heterogeneity by race and ethnicity = 0.009) and weaker in Latino women (P for heterogeneity = 0.002).

CONCLUSION

A healthy plant-based dietary pattern emphasizing the quality of plant foods was associated with a lower risk of all-cause and CVD mortality in both men and women, although the magnitude of the associations varied across racial and ethnic groups.

A high consumption of ultra-processed foods is associated with higher total mortality in an adult Mediterranean population

BACKGROUND & AIMS

The consumption of ultra-processed foods (UPF) has been associated with higher all-cause and cardiovascular disease (CVD) mortality, although this association has not been sufficiently investigated in Mediterranean populations. We aimed to evaluate the association between UPF consumption and all-cause, CVD and cancer mortality in an adult population in Spain.

METHODS

We analysed data from 1,538 participants aged 20 years and above in the Valencia Nutrition Survey in 1995. Diet was assessed at baseline using a validated food frequency questionnaire and the consumption of UPF was calculated using the NOVA system. Information on socio-demographic characteristics, lifestyles, and presence of diseases was also collected at baseline. Cause of death was ascertained during an 18-year follow-up period. We used Cox regression and competing risk models as proposed by Fine and Gray's to estimate adjusted hazard ratios (HR) and 95 % confidence intervals (95 %CI).

RESULTS

After 18 years of follow-up, we documented 312 deaths (36.5 % of CVD and 25.6 % of cancer). Compared with participants in the lowest tertile of UPF consumption, those in the highest tertile showed 40 % higher risk of all-cause mortality, HR 1.40 (95 %CI: 1.04-1.90), and evidence of a higher CVD mortality, HR 1.39 (95 %CI: 0.80-2.41) and of cancer mortality, HR 1.53 (95 %CI: 0.83-2.82).

CONCLUSIONS

This study suggests that a high UPF consumption is associated with a higher all-cause mortality in a Mediterranean population after a long follow-up period. Considering the increase in UPF consumption and their detrimental health effects on mortality, these results should be confirmed by other studies in other populations.

Association between brown sugar intake and decreased risk of cancer in the Amami islands region, Japan

BACKGROUND AND OBJECTIVES

Although excess white sugar intake imposes various health burdens, brown sugar is high in minerals, polyphenols, and polycosanol. However, few epidemiological studies have assessed brown sugar intake for health benefit. People in the Amami islands region, with a relatively high proportion of individuals with longevity, consume brown sugar as a type of refreshment. This cohort study was conducted in Amami to clarify the association of brown sugar intake with mortality risk and cancer incidence.

METHODS AND STUDY DESIGN

Participants were recruited from the general population of Amami as part of the Japan Multi-Institutional Collaborative Cohort Study. The number of eligible participants was 5004 (2057 men and 2947 women). During the median follow-up period of 13.4 years, 274 deaths and 338 cases of cancer were observed. HRs and 95% CIs were estimated using the Cox proportional hazard model, after adjusting for sugar-related and other variables.

RESULTS

After adjusting for their related confounding factors, brown sugar intake was associated with decreased HRs and a decreasing trend for all-site and stomach cancer incidence (p = 0.001 and 0.017, respectively) in women and men, and for breast cancer incidence (p = 0.034) in women. Additionally, a decreasing trend in the HRs for lung cancer incidence was observed among never and ex-smokers (p = 0.039). Decreased HRs for overall death, cancer, and cardiovascular disease were not apparent.

CONCLUSIONS

Brown sugar intake was associated with decreased risk of all-site, stomach, and breast cancer incidences in the Amami population.

Associations of dietary sugar types with coronary heart disease risk: a prospective cohort study

BACKGROUND

Higher intake of total sugar has been linked with coronary heart disease (CHD) risk, but the role of individual sugars, particularly fructose, is uncertain.

OBJECTIVES

This study aimed to investigate the associations of individual dietary sugars with CHD risk.

METHODS

In prospective cohort studies, we followed 76,815 women (Nurses' Health Study, 1980-2020) and 38,878 men (Health Professionals Follow-up Study, 1986-2016). Sugar and carbohydrate intake, including total fructose equivalents ([TFE] from fructose monosaccharides and sucrose), total glucose equivalents ([TGE] from glucose monosaccharides, disaccharides, and starch), and other sugar types, was measured every 2 to 4 y by semiquantitative food frequency questionnaires.

RESULTS

We documented 9,723 incident CHD cases over 40 years. In isocaloric substitution models with total fat as a comparison nutrient, comparing extreme quintiles of intake, hazard ratios (HRs), 95% confidence interval [CI]) for CHD risk were 1.31 (1.20 to 1.42; Ptrend < 0.001) for TGE and 1.03 (0.94 to 1.11; Ptrend = 0.25) for TFE. TFE from fruits and vegetables was not associated with CHD risk (Ptrend = 0.70), but TFE from added sugar and juice was associated with CHD risk (HR: 1.12, 95% CI: 1.04 to 1.20; Ptrend < 0.01). Intakes of total sugars and added sugar were positively associated with CHD risk (HRs: 1.16, 95% CI: 1.07 to 1.26, Ptrend < 0.001; 1.08, 95% CI: 0.99 to 1.16, Ptrend = 0.04).

CONCLUSIONS

Intakes of TGE, total sugar, added sugar, and fructose from added sugar and juice were associated with higher CHD risk, but TFE and fructose from fruits and vegetables were not.

Association of sugar-sweetened beverages with the risk of colorectal cancer: a systematic review and meta-analysis

The association between sugar-sweetened beverages intake and colorectal cancer (CRC) remains controversial. A metaanalysis was performed to clarify the correlation between sugar-sweetened beverages and CRC risk/mortality. A systematic literature search was conducted in PubMed, Web of Science, Embase, China National Knowledge Infrastructure (CNKI), Sinomed (CBM), Wanfang Data Knowledge Service Platform, and China Science and Technology Journal VIP database. Articles were restricted to be available in any language until March 31, 2022. The highest exposed categories were used to calculate the pooled relative risks (RR) values. Pooled relative risks (RR) and 95% confidence intervals (CI) were used to estimate the association of sugar-sweetened beverages with CRC risk and mortality. Heterogeneity was assessed with the Cochran Q statistic and quantified with the I2 statistic. A total of 17 studies (6 case-control and 11 cohort) involving 557,391 subjects were included in this meta-analysis. The pooled RRs for CRC incidence and mortality among people taking sugar-sweetened beverages were 1.17 (95% CI: 1.07-1.28) and 1.13 (95% CI: 0.99-1.29), respectively. In subgroup analysis, a correlation was found in the distal colon with a pooled RR of 1.41 (95% CI: 1.10-1.80). There was no correlation in the proximal colon with a pooled RR of 1.58 (95% CI: 0.79-3.17). We found statistically significant associations between CRC incidence and sugar-sweetened beverages intake in North America and Oceania, with pooled RRs of 1.16 (95% CI: 1.00-1.33) and 1.32 (95% CI: 1.13-1.55), respectively. In sensitivity analysis, after excluding each study and calculating heterogeneity and effect sizes, there was still a correlation between sugar-sweetened beverages intake and CRC risk. This meta-analysis suggests that sugar-sweetened beverages intake may increase CRC risk, independent of CRC mortality. Whether CRC risk increases with increased sugar-sweetened beverage intake needs further investigation in the future. This meta-analysis aimed to indicate the relationship between sugar-sweetened beverages intake and the risk and mortality of colorectal cancer. A total of 17 studies involving 557,391 subjects were included. The results showed that sugar-sweetened beverages may increase the risk of colorectal cancer but may not be associated with colorectal cancer mortality.

Significant Dose-Response Association of Physical Activity and Diet Quality With Mortality in Adults With Suspected NAFLD in a Population Study

INTRODUCTION

We aimed to determine whether higher levels (volume and intensity) of physical activity (PA) and diet quality (DQ) are associated with better survival rates in nonalcoholic fatty liver disease (NAFLD).

METHODS

Using data from the 2011-2014 National Health and Nutrition Examination Survey, 3,548 participants with a Fatty Liver Index ≥60 were included. PA was collected using a wrist-worn triaxial accelerometer and expressed as 2 metrics using Monitor-Independent Movement Summary (MIMS) units: the average of daily MIMS, which represents volume, and peak 30-minute MIMS, which is the average of the highest 30 MIMS min/d and represents intensity. DQ was assessed by the Healthy Eating Index-2015. Mortality follow-up was recorded using the National Death Index linkage through December 31, 2019.

RESULTS

Our analyses revealed a dose-dependent, nonlinear association of PA (volume and intensity) with all-cause mortality and a dose-dependent, linear association of DQ with all-cause mortality. The maximum protective dose of PA volume was observed at 14,300 MIMS/min (adj. HR: 0.20, 95% CI: 0.11-0.38). The maximum protective dose of PA intensity was observed at 54.25 MIMS/min (adj. HR: 0.10, 95% CI: 0.05-0.23), beyond which mortality risks flattened. The Healthy Eating Index-2015 showed its maximum protective effect at 66.17 (adj. HR: 0.54, 95% CI: 0.40-0.74). Higher PA (volume and intensity) levels were associated with a lower risk of cardiovascular-related but not cancer-related mortality. A healthier diet was linked to a reduced risk of cardiovascular-specific and cancer-specific mortality. Sensitivity analyses showed that the beneficial effects of PA and DQ on survival rates remained significant across sex, racial/ethnic, and age groups as well as in participants without NAFLD.

DISCUSSION

Our findings suggest that higher daily accumulated and peak effort PA and DQ are associated with lower all-cause and cardiovascular mortality in US adults with NAFLD.

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.

Prospective Cohort of Pre- and Post-Diagnosis Diet with Survival Outcomes: an Alberta Endometrial Cancer Cohort Study

BACKGROUND

The prognostic relationship between diet and endometrial cancer survival remains largely unknown. We sought to determine pre- and post-diagnosis dietary composition, glycemic load (GL), inflammatory potential (dietary inflammatory index) and quality [Canadian Healthy Eating Index (C-HEI) 2005] associations with disease-free (DFS) and overall survival (OS) among endometrial cancer survivors. In addition, we assessed associations between dietary changes with OS and explored obesity/physical activity effect modification.

METHODS

Survivors, diagnosed in Alberta, Canada between 2002 and 2006, completed past-year, food-frequency questionnaires at-diagnosis (n = 503) and 3-year follow-up (n = 395). Participants were followed to death or January 2022. Cox proportional regression estimated HR [95% confidence intervals (CI)] for dietary survival associations.

RESULTS

During 16.9 median years of follow-up, 138 participants had a DFS event and 120 died. Lower pre-diagnosis GL (HRT1vsT3, 0.49; 95% CI, 0.25-0.97) and greater post-diagnosis energy intakes (EI) from total- and monounsaturated-fat (HRT3vsT1, 0.48; 95% CI, 0.26-0.87) were associated with better OS. Higher pre-diagnosis C-HEI, less inflammatory diets and lower added sugar intakes were nonlinearly associated with better DFS. Consistently low pre- to post-diagnosis EI from carbohydrates and total-fats were associated with better (HR, 0.36; 95% CI, 0.18-0.72) and worse (HR, 2.26; 95% CI, 1.21-4.20) OS, respectively. Decreased pre- to post-diagnosis C-HEI was associated with worse OS. In stratified analysis, healthy diets were most beneficial for survivors with obesity and physical inactivity.

CONCLUSIONS

Adherence to higher quality dietary patterns were associated with better survival.

IMPACT

Our study provides novel evidence that both pre- and post-diagnosis diet are important prognostic factors for endometrial cancer survivors. Post-diagnosis survival associations with diet composition and quality highlight the potential for future interventions.

Association of sweetened beverages consumption with all-cause mortality risk among Dutch adults: the Lifelines Cohort Study (the SWEET project)

PURPOSE

Examined associations between sugar-sweetened beverages (SSB), low/no-calorie beverages (LNCB), and fruit juice (FJ) consumption and all-cause mortality in Dutch adults.

METHODS

Data of 118,707 adults participating (mean age = 45 years; 60% was women) the Lifelines Cohort Study were prospectively analyzed. Dietary intake was assessed using a validated food-frequency questionnaire. Participants' vital status was followed-up until February 2022 via the National Personal Records Database. Associations between beverages of interest and all-cause mortality risk were investigated using restricted cubic spline and Cox proportional hazard regression analyses, including substitution analyses. Models were adjusted for demographics, lifestyle, and other dietary factors.

RESULTS

During follow-up (median = 9.8 years), a total of 2852 (2.4%) deaths were documented. Median (IQR) of SSB, LNCB, and FJ consumption were 0.1 (0.0-0.6), 0.1 (0.0-0.6), and 0.2 (0.0-0.6) serving/day, respectively. Dose-response analyses showed linear associations between SSB, LNCB, and FJ consumption and mortality risk. For each additional serving of SSB and LNCB, HRs of all-cause mortality risk were 1.09 (95% CI 1.03-1.16) and 1.06 (95% CI 1.00-1.11). Replacing SSB with LNCB showed a nonsignificant association with a lower mortality risk, particularly in women (HR 0.91, 95% CI 0.81-1.01). Finally, an inverse association between FJ and all-cause mortality was observed at moderate consumption with HR of 0.87 (95% CI 0.79-0.95) for > 0-2 servings/week and HR of 0.89 (95% CI 0.81-0.98) for > 2-< 7 servings/week when compared to no consumption.

CONCLUSIONS

Our study showed adverse associations between SSB consumption and all-cause mortality. Replacing SSB with LNCB might be associated with lower mortality risk, particularly in women. Moderate intake of FJ was associated with lower all-cause mortality risk.

Effect of lifelong sucrose consumption at human-relevant levels on food intake and body composition of C57BL/6N mice

Introduction

Controversies surround the issue if chronic consumption of a high-sugar diet is detrimental to health or not. This study investigates whether lifelong consumption of a higher sucrose diet will induce overeating, and obesity, and cause metabolic dysfunctions such as hyperglycemia and dyslipidaemia in C57BL/6N mice, compared to a lower sucrose diet.

Methods

Male C57BL/6N mice at 3 weeks of age were randomized into consuming a diet with 25 or 10% kcal from sucrose for the rest of their lives. Body weight, food and water intake, fasting blood glucose, insulin, and lipid levels were measured at regular intervals. At the end of the study, organs and tissues were collected and gene expression was measured.

Results

There was no discernible difference in the impact on food intake, body composition, glucose and lipid homeostasis, liver triglyceride content, life expectancy, as well as gene expression related to intermediary metabolism between mice fed a diet with 10 vs. 25% kcal as sucrose over their lifespan. We also showed that switching from a 25% kcal diet to a 10% kcal diet at different life stages, or vice versa, did not appear to affect these outcomes of interest.

Discussion

The results from our study suggest that lifelong consumption of a higher sugar diet generally did not induce overeating and obesity, disrupt carbohydrate metabolism and lipid homeostasis, and reduce life expectancy compared with a lower sugar diet. Our unorthodox findings disagreed with the popular belief that higher sugar consumption is detrimental to health, which should be confirmed in future studies.

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.

Association of all-cause mortality with sugar intake from different sources in the prospective cohort of UK Biobank participants

The present study elucidates the association of intrinsic sugars and free sugars (FS) from all relevant sources with all-cause mortality in the prospective UK Biobank cohort. Sugar intake was assessed in 186 811 UK Biobank participants who completed at least one web-based 24-h dietary recall (Oxford WebQ). Cox proportional hazard regression models for all-cause mortality were used with sugar intake from different sources included as penalised cubic splines to allow non-linear predictor effects. Over a mean follow-up of 12·3 years, 8576 (4·6 %) deaths occurred. FS but not intrinsic sugars were significantly and dose-dependently associated with hazard ratio (HR) for all-cause mortality. The association with all-cause mortality was significant and dose dependent for FS in beverages, but not in solids with the mean (CI) HR at 50 g/d v. 0 g/d consumption at 1·10, 95 % CI (1·07, 1·14) and 1·01, 95 % CI (0·98, 1·03), respectively. Within the beverages subcategories, a significant dose-dependent association with mortality was detected for FS in soda/fruit drinks and milk-based drinks whereas this relation was NS for FS in pure juice and tea/coffee. FS in four different subtypes of solids, i.e. treats, cereals, toppings and sauces, were not positively associated with all-cause mortality. Major findings were robust in sensitivity analyses. In conclusion, only some FS sources were associated with all-cause mortality. Interventions targeting FS subtypes might be most effective concerning mortality if focused on the reduction of soda/fruit drinks and milk-based sugary drinks; however, the present results need to be confirmed by independent studies.

Association Between Ultra-Processed Food Intake and All-Cause Mortality: A Systematic Review and Meta-Analysis

Consumption of ultra-processed foods (UPF) has increased worldwide during the last decades because they are hyperpalatable, cheap, and ready-to-consume products. However, uncertainty exists about their impact on health. We conducted a systematic review and meta-analysis evaluating the association of UPF consumption with all-cause mortality risk. Five bibliographic databases were searched for relevant studies. Random effects models were used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). Of 6,951 unique citations, 40 unique prospective cohort studies comprising 5,750,133 individuals were included; publication dates ranged from 1984 to 2021. Compared with low consumption, highest consumption of UPF (RR = 1.29, 95% CI: 1.17, 1.42), sugar-sweetened beverages (RR = 1.11, 95% CI, 1.04, 1.18), artificially sweetened beverages (RR = 1.14, 95% CI, 1.05, 1.22), and processed meat/red meat (RR = 1.15, 95% CI, 1.10, 1.21) were significantly associated with increased risk of mortality. However, breakfast cereals were associated with a lower mortality risk (RR = 0.85, 95% CI, 0.79, 0.92). This meta-analysis suggests that high consumption of UPF, sugar-sweetened beverages, artificially sweetened beverages, processed meat, and processed red meat might increase all-cause mortality, while breakfast cereals might decrease it. Future studies are needed to address lack of standardized methods in UPF categorization.

Current WHO recommendation to reduce free sugar intake from all sources to below 10% of daily energy intake for supporting overall health is not well supported by available evidence

Sugar is widely consumed over the world. Although the mainstream view is that high added or free sugar consumption leads to obesity and related metabolic diseases, controversies exist. This narrative review aims to highlight important findings and identify major limitations and gaps in the current body of evidence in relation to the effect of high sugar intakes on health. Previous animal studies have shown that high sucrose or fructose consumption causes insulin resistance in the liver and skeletal muscle and consequent hyperglycemia, mainly because of fructose-induced de novo hepatic lipogenesis. However, evidence from human observational studies and clinical trials has been inconsistent, where most if not all studies linking high sugar intake to obesity focused on sugar-sweetened beverages (SSBs), and studies focusing on sugars from solid foods yielded null findings. In our opinion, the substantial limitations in the current body of evidence, such as short study durations, use of supraphysiological doses of sugar or fructose alone in animal studies, and a lack of direct comparisons of the effects of solid compared with liquid sugars on health outcomes, as well as the lack of appropriate controls, seriously curtail the translatability of the findings to real-world situations. It is quite possible that "high" sugar consumption at normal dietary doses (e.g., 25% daily energy intake) per se-that is, the unique effect of sugar, especially in the solid form-may indeed not pose a health risk for individuals apart from the potential to reduce the overall dietary nutrient density, although newer evidence suggests "low" sugar intake (<5% daily energy intake) is just as likely to be associated with nutrient dilution. We argue the current public health recommendations to encourage the reduction of both solid and liquid forms of free sugar intake (e.g., sugar reformulation programs) should be revised due to the overextrapolation of results from SSBs studies.

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.

Tolerable upper intake level for dietary sugars

Following a request from five European Nordic countries, the EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA) was tasked to provide scientific advice on a tolerable upper intake level (UL) or a safe level of intake for dietary (total/added/free) sugars based on available data on chronic metabolic diseases, pregnancy-related endpoints and dental caries. Specific sugar types (fructose) and sources of sugars were also addressed. The intake of dietary sugars is a well-established hazard in relation to dental caries in humans. Based on a systematic review of the literature, prospective cohort studies do not support a positive relationship between the intake of dietary sugars, in isocaloric exchange with other macronutrients, and any of the chronic metabolic diseases or pregnancy-related endpoints assessed. Based on randomised control trials on surrogate disease endpoints, there is evidence for a positive and causal relationship between the intake of added/free sugars and risk of some chronic metabolic diseases: The level of certainty is moderate for obesity and dyslipidaemia (> 50-75% probability), low for non-alcoholic fatty liver disease and type 2 diabetes (> 15-50% probability) and very low for hypertension (0-15% probability). Health effects of added vs. free sugars could not be compared. A level of sugars intake at which the risk of dental caries/chronic metabolic diseases is not increased could not be identified over the range of observed intakes, and thus, a UL or a safe level of intake could not be set. Based on available data and related uncertainties, the intake of added and free sugars should be as low as possible in the context of a nutritionally adequate diet. Decreasing the intake of added and free sugars would decrease the intake of total sugars to a similar extent. This opinion can assist EU Member States in setting national goals/recommendations.

High versus low-added sugar consumption for the primary prevention of cardiovascular disease

BACKGROUND

High intake of added sugar have been suggested to impact the risk for cardiovascular disease (CVD). Knowledge on the subject can contribute to preventing CVD.

OBJECTIVES

To assess the effects of a high versus low-added sugar consumption for primary prevention of CVD in the general population.

SEARCH METHODS

We searched Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, Conference Proceedings Citation Index-Science (CPCI-S) on 2 July 2021. We also conducted a search of ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) Search Portal for ongoing or unpublished trials. The search was performed together with reference checking, citation searching and contact with study authors to identify additional studies. We imposed no restriction on language of publication or publication status.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), including cross-over trials, that compared different levels of added sugar intake. Exclusion criteria were: participants aged below 18 years; diabetes mellitus (type 1 and 2); and previous CVD. Primary outcomes were incident cardiovascular events (coronary, carotid, cerebral and peripheral arterial disease) and all-cause mortality. Secondary outcomes were changes in systolic and diastolic blood pressure, total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, fasting plasma glucose and adverse events (gastrointestinal symptoms and impaired dental health).

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 21 RCTs (1110 participants completing the interventions) examining the effects of different levels of added sugar intake with a mean duration of 14 weeks. The study participants were generally described as healthy and the mean age ranged from 22 to 57 years. No studies reported on cardiovascular events or all-cause mortality. There was minimal effect of low intake of added sugar on total cholesterol levels (MD 0.11, 95% CI 0.01 to 0.21; I² = 0%; 16 studies; 763 participants; low certainty of evidence) and triglycerides (MD 0.10, 95% CI 0.03 to 0.17; I² = 3%; 14 studies; 725 participants) but no evidence of effect on LDL-cholesterol and HDL-cholesterol. There was minimal effect on diastolic blood pressure (MD 1.52, 95% CI 0.67 to 2.37; I² = 0%; 13 studies; 873 participants) and on systolic blood pressure (MD 1.44, 95% 0.08 to 2.80; I² = 27%, 14 studies; 873 participants; low certainty of evidence), but no evidence of effect on fasting plasma glucose. Only one study reported on dental health, with no events. No other trials reported adverse events (impaired dental health or gastrointestinal symptoms). All results were judged as low-quality evidence according to GRADE. The risk of bias was generally unclear, five studies were classified at an overall low risk of bias (low risk in at least four domains, not including other bias).

AUTHORS' CONCLUSIONS

No trials investigating the effect of added sugar on cardiovascular events or all-cause mortality were identified in our searches. Evidence is uncertain whether low intake of added sugar has an effect on risk factors for CVD; the effect was small and the clinical relevance is, therefore, uncertain. Practical ways to achieve reductions in dietary added sugar includes following current dietary recommendations. Future trials should have longer follow-up time and report on all-cause mortality and cardiovascular events in order to clarify the effect of added sugar on these outcomes. Future trials should also aim for more direct interventions and preferably be more independent of industry funding.

Association of added sugar intake with all-cause and cardiovascular disease mortality: a systematic review of cohort studies

BACKGROUND/OBJECTIVES

The long-term health impacts of dietary sugar have begun to be reported. The committee on the 2020 Dietary Reference Intakes for Koreans for sugar intended to update the scientific evidence on the association of added sugar intake with health outcomes, including mortality. This study evaluated the evidence on the association of dietary sugar with the all-cause and cardiovascular disease mortality from cohort studies.

SUBJECTS/METHODS

The PubMed and ScienceDirect databases were searched until July 2021. The search terms were based on multiple combinations of keywords, such as added sugar, beverage, and mortality, included in the title or abstract. Two authors independently assessed the eligibility criteria of study selection and extracted the information from each selected article for this systematic review.

RESULTS

The literature search identified 276 articles. Seventeen cohort studies met the inclusion criteria and were included in this systematic review. This study extracted information on the cohort and participants, dietary assessment methods, exposure and its comparison groups, health outcomes, and risk measures. Five articles reported added sugar intake, and 15 articles reported the food sources of the added sugar in the association with mortality. Increased mortality was observed in higher added sugar intake and a lower intake of less than 5% of energy, while higher discrepancies between gender, age groups, and countries were noted. In addition, nutritious sugary foods and beverages did not increase mortality.

CONCLUSIONS

A ‘U’ or ‘J’ shaped relationship between the added sugar intake and mortality was estimated. The observed discrepancy indicated the need for more evidence to establish the dose-response relationship for Koreans.

Types of carbohydrate intake and breast cancer survival

OBJECTIVE

To investigate the associations of different types of carbohydrate intake after breast cancer diagnosis with breast cancer-specific and all-cause mortality.

METHODS

We prospectively assessed post-diagnostic intake of total sugar, added sugar, and natural sugar as well as carbohydrate from different sources, among 8932 women with stage I-III breast cancer that were identified in the Nurses' Health Study from 1980 to 2010 and Nurses' Health Study II from 1991 to 2011. Participants completed a validated food frequency questionnaire every four years after diagnosis and were followed up for death.

RESULTS

We prospectively documented 1071 deaths due to breast cancer and 2532 all-cause deaths, over a mean of 11.5 years of follow-up. After adjustment for confounding variables, greater post-diagnostic total sugar intake was suggestively associated with greater risk of breast cancer-specific mortality [hazard ratio (HR)_Q5vsQ1 = 1.16, 95% confidence interval (CI ) = 0.95-1.41; P_trend = 0.02] and significantly associated with greater risk of all-cause mortality (HR_Q5vsQ1 = 1.23, 95% CI = 1.08-1.41; P_trend = 0.0001). Greater post-diagnostic added sugar intake was significantly associated with greater risk of all-cause mortality (HR_Q5vsQ1 = 1.20, 95% CI = 1.06-1.36; P_trend = 0.001). Post-diagnostic natural sugar (occurring in foods and not added as an ingredient) intake was not associated with mortality risk. Greater post-diagnostic fructose intake was significantly associated with greater risk of breast cancer-specific mortality (HR_Q5vsQ1 = 1.34, 95% CI = 1.10-1.64; P_trend = 0.005) and all-cause mortality (HR_Q5vsQ1 = 1.16, 95% CI = 1.02-1.32; P_trend = 0.01). High post-diagnostic intake of sucrose was associated with higher risk of breast cancer-specific and all-cause mortality. Increased post-diagnostic intake of carbohydrate from fruit juice was significantly associated with higher risk of breast cancer-specific and all-cause mortality and carbohydrate from vegetables was significantly associated with lower risk of all-cause mortality. High post-diagnostic intake of carbohydrate from potatoes was suggestively associated with higher risk of breast cancer-specific mortality and carbohydrate from refined grains was suggestively associated with higher risk of all-cause mortality.

CONCLUSIONS

We found that higher total sugar intake, especially added sugar, sucrose, and fructose, as well as carbohydrate from fruit juice after a breast cancer diagnosis were associated with poorer prognosis. High post-diagnostic intake of carbohydrate from vegetables was associated with reduced risk of mortality.

Artificial Intelligence in Functional Food Ingredient Discovery and Characterisation: A Focus on Bioactive Plant and Food Peptides

Scientific research consistently demonstrates that diseases may be delayed, treated, or even prevented and, thereby, health may be maintained with health-promoting functional food ingredients (FFIs). Consumers are increasingly demanding sound information about food, nutrition, nutrients, and their associated health benefits. Consequently, a nutrition industry is being formed around natural foods and FFIs, the economic growth of which is increasingly driven by consumer decisions. Information technology, in particular artificial intelligence (AI), is primed to vastly expand the pool of characterised and annotated FFIs available to consumers, by systematically discovering and characterising natural, efficacious, and safe bioactive ingredients (bioactives) that address specific health needs. However, FFI-producing companies are lagging in adopting AI technology for their ingredient development pipelines for several reasons, resulting in a lack of efficient means for large-scale and high-throughput molecular and functional ingredient characterisation. The arrival of the AI-led technological revolution allows for the comprehensive characterisation and understanding of the universe of FFI molecules, enabling the mining of the food and natural product space in an unprecedented manner. In turn, this expansion of bioactives dramatically increases the repertoire of FFIs available to the consumer, ultimately resulting in bioactives being specifically developed to target unmet health needs.

Chronic liquid fructose supplementation does not cause liver tumorigenesis but elicits clear sex differences in the metabolic response in Sprague-Dawley rats

Background

Non-alcoholic fatty liver disease (NAFLD) has increased over the last decades and may evolve into hepatocellular carcinoma (HCC). As HCC is challenging to treat, knowledge on the modifiable risk factors for NAFLD/HCC (e.g. hyper caloric diets rich in fructose) is essential.

Objective and design

We used a model of diethyl nitrosamine-induced hepatocarcinogenesis to investigate the liver cancer-promoting effects of a diet supplemented with 10% liquid fructose, administered to male and female rats for 11 months. A subset of the fructose-supplemented rats received resveratrol (RVT) in the last 4 months of treatment.

Results and discussion

Rat livers showed no de visu or histological evidence of liver tumorigenesis. However, we observed metabolic abnormalities that could be related to cancer development mainly in the female fructose-supplemented rats, such as increases in weight, adiposity and hepatic triglyceride levels, as well as hyperglycaemia, hyperuricemia, hyperleptinemia and a reduced insulin sensitivity index, which were partially reversed by RVT. Therefore, we performed a targeted analysis of 84 cancer-related genes in the female liver samples, which revealed expression changes associated with cancer-related pathways. Analysis of individual genes indicated that some changes increased the risk of hepatocarcinogenesis (Sfrp2, Ccl5, Socs3, and Gstp1), while others exerted a protective/preventive effect (Bcl2 and Cdh1).

Conclusion

Our data clearly demonstrate that chronic fructose supplementation, as the sole dietary intervention, does not cause HCC development in rats.

Simple sugar intake and cancer incidence, cancer mortality and all-cause mortality: A cohort study from the PREDIMED trial

OBJECTIVE

To examine associations between intake of simple sugars and cancer incidence, cancer mortality, and total mortality in a prospective cohort study based on the PREDIMED trial conducted from 2003 to 2010.

METHODS

Participants were older individuals at high cardiovascular risk. Exposures were total sugar, glucose and fructose from solid or liquid sources, and fructose from fruit and 100% fruit juice. Cancer incidence was the primary outcome; cancer mortality and all-cause mortality were secondary outcomes. Multivariable-adjusted, time-dependent Cox proportional hazard models were used.

RESULTS

Of 7447 individuals enrolled, 7056 (94.7%) were included (57.6% women, aged 67.0 ± 6.2 years). 534 incident cancers with 152 cancer deaths and 409 all-cause deaths were recorded after a median follow-up of 6 years. Intake of simple sugars in solid form was unrelated to outcomes. Higher cancer incidence was found per 5 g/day increase in intake of liquid sugars, with multivariable-adjusted HR of 1.08 (95% CI, 1.03-1.13) for total liquid sugar, 1.19 (95% CI, 1.07-1.31) for liquid glucose, 1.14 (95% CI, 1.05-1.23) for liquid fructose, and 1.39 (95% CI, 1.10-1.74) for fructose from fruit juice. Cancer and all-cause mortality increased to a similar extent with intake of all sugars in liquid form. In categorical models, cancer risk was dose-related for all liquid sugars.

CONCLUSIONS

Simple sugar intake in drinks and fruit juice was associated with an increased risk of overall cancer incidence and mortality and all-cause mortality. This suggests that sugary beverages are a modifiable risk factor for cancer and all-cause mortality.

Sugar-sweetened beverage, artificially sweetened beverage and sugar intake and colorectal cancer survival

BACKGROUND

The influence of a high sugar diet on colorectal cancer (CRC) survival is unclear.

METHODS

Among 1463 stage I-III CRC patients from the Nurses' Health Study and Health Professionals Follow-up Study, we estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for CRC-specific and all-cause mortality in relation to intake of post-diagnosis sugar-sweetened beverages (SSB), artificially sweetened beverages (ASB), fruit juice, fructose and other sugars.

RESULTS

Over a median 8.0 years, 781 cases died (173 CRC-specific deaths). Multivariable-adjusted HRs for post-diagnosis intake and CRC-specific mortality were 1.21 (95% CI: 0.87-1.68) per 1 serving SSBs per day (serving/day) and 1.24 (95% CI: 0.95-1.63) per 20 grams fructose per day. Significant positive associations for CRC-specific mortality were primarily observed ≤5 years from diagnosis (HR per 1 serving/day of SSBs = 1.59, 95% CI: 1.06-2.38). Significant inverse associations were observed between ASBs and CRC-specific and all-cause mortality (HR for ≥5 versus <1 serving/week = 0.44, 95% CI: 0.26-0.75 and 0.70, 95% CI: 0.55-0.89, respectively).

CONCLUSIONS

Higher post-diagnosis intake of SSBs and sugars may be associated with higher CRC-specific mortality, but only up to 5 years from diagnosis, when more deaths were due to CRC. The inverse association between ASBs and CRC-specific mortality warrants further examination.

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

Sugar-sweetened beverages (SSBs), artificially sweetened beverages (ASBs), and 100% fruit juices are frequently consumed and have been documented that they could lead to serious disease burden. However, inconsistent evidence on the association between SSBs, ASBs, and 100% fruit juices consumption and mortality have been presented. PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and PsycINFO were systematically searched. We conducted a random-effects meta-analysis and dose-response meta-analysis to assess the association and calculated the pooled hazard ratio with 95% confidence interval. And we evaluated the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Thirteen studies with 1,539,127 participants proved eligible. An SSB-consumption increase per 250 mL/day was associated with a 4% greater risk of all-cause mortality (5 more per 1000 persons; low certainty) and 8% greater risk of cardiovascular disease mortality (3 more per 1000 persons; low certainty). ASB-consumption increase per 250 mL/day demonstrated a 4% greater risk of all-cause mortality (5 more per 1000 persons; low certainty) and 4% greater risk of cardiovascular disease mortality (2 more per 1000 persons; low certainty). The association of SSBs and ASBs with cancer mortality was not significant, with a very low certainty of evidence. There was evidence of a linear dose-response association between SSB intake and cancer mortality, as well as between ASB intake and all-cause mortality and cancer mortality. We observed a non-linear dose-response association between ASB intake and CVD mortality and SSB intake and all-cause and CVD mortality. Low certainty of evidence demonstrated that per 250 mL/day consumption increase in SSBs and ASBs had a small impact on all-cause and cardiovascular disease mortality but not on cancer mortality. The association of 100% fruit juice consumption with all-cause and cardiovascular disease mortality was uncertain.

Association between intake of sweetened beverages with all-cause and cause-specific mortality: a systematic review and meta-analysis

BACKGROUND

Conclusions remain controversial between the consumption of sugar and artificially sweetened beverages (SSBs and ASBs) and mortality.

METHODS

We systematically searched the PubMed, Embase, Cochrane Library and Web of Science databases from their inception date to 1st January 2020, prospective cohort studies researching the mortality risk and SSBs or ASBs consumption were included. Random effects meta-analyses and dose-response analyses were performed to measure the association. Subgroup analyses and sensitivity analyses were further performed to explore the source of heterogeneity. Publication bias was assessed by Funnel plots and Egger's regression test.

RESULTS

Across all 15 cohorts, 1211 470 participants were included. High SSB consumption was associated with a higher risk of all-cause mortality (hazard ratio [HR], 1.12; 95% confidence interval [CI], 1.06-1.19, P < 0.001; and cardiovascular disease [CVD] mortality [HR 1.20, 95% CI, 1.05-1.38, P < 0.001]), and high ASBs consumption showed similar result (HR 1.12, 95% CI, 1.04-1.21, P = 0.001 for all-cause mortality and HR 1.23, 95% CI, 1.00-1.50, P = 0.049 for CVD mortality), both showed a linear dose-response relationship.

CONCLUSIONS

High consumption of both ASBs and SSBs showed significant associations with a higher risk of CVD mortality and all-cause mortality. This information may provide ideas for decreasing the global burden of diseases by reducing sweetened beverage intake.

Consumption of sugar-sweetened beverages and fruit juice and human cancer: a systematic review and dose-response meta-analysis of observational studies

Background: Several epidemiological studies have assessed the association of sugary drinks consumption with cancer, but the results remain controversial. Objective: We performed this analysis to evaluate possible causal relationship between sugary drinks consumption and cancer risk and mortality. Methods: We searched PubMed, Embase, and Web of Science databases in English. Observational studies evaluating the association of sugary drinks intake with cancer were included. Random-effects meta-analysis was used to calculate the risk estimates. Results: A total of 71 observational articles with 32 case-control and 39 cohort studies were included in the meta-analysis. 60 addressed cancer risk, and 11 reported cancer mortality. Compared with the lowest level, the highest level of sugar-sweetened beverages (SSB) consumption showed an increased overall cancer risk (RR=1.12 95% CI: 1.06-1.19, P=0.000) and mortality (RR=1.07 95% CI: 1.01-1.14, P=0.029), and fruit juice intake showed a positive association with cancer risk in cohort studies (RR=1.06 95% CI: 1.01-1.11, P=0.013). Subgroup analyses based on cancer type indicated that risk of breast cancer, hepatocellular carcinoma, colorectal cancer, and prostatic cancer mortality had a positive association with SSB consumption. For dose-response analysis, evidence of a linear association was found between overall cancer risk and SSB or fruit juice consumption, and the risk increase by 4% for one servings/d increment in SSB intake and 14% in fruit juice. Conclusions: Our findings suggest the consumption of sugary beverages may increase the risk and mortality of cancer, especially risk of breast cancer, hepatocellular carcinoma, colorectal cancer, and prostatic cancer, and mortality of breast cancer, though the evidence was limited.

A review of lifestyle and environment risk factors for pancreatic cancer

Pancreatic cancer (PaCa) is one of the deadliest cancers known and its incidence is increasing in the developed countries. Because of the lack of biomarkers that allow early detection and the tendency of the disease to be asymptomatic, the diagnosis comes often too late for effective surgical or chemotherapy intervention. Lifestyle factors, that may cause common genetic modifications occurring in the disease, interfere with pancreatic physiology or function, and play a role in PaCa development, have been of concern recently, since a strategy to prevent this severe cancer is needed. This review identifies the latest evidences related to increased risk of developing PaCa due to dietary habits such as high alcohol, fructose and red or processed meat intake, and pathological conditions such as diabetes, obesity and infections in addition to stress and smoking behaviour. It aims to highlight the importance of intervening on modifiable risk factors: the action on these factors could prevent a considerable number of new cases of PaCa.

Associations Between Added Sugar Intake and Risk of Four Different Cardiovascular Diseases in a Swedish Population-Based Prospective Cohort Study

Aims: Although diet is one of the main modifiable risk factors of cardiovascular disease, few studies have investigated the association between added sugar intake and cardiovascular disease risk. This study aims to investigate the associations between intake of total added sugar, different sugar-sweetened foods and beverages, and the risks of stroke, coronary events, atrial fibrillation and aortic stenosis.

Methods: The study population consists of 25,877 individuals from the Malmö Diet and Cancer Study, a Swedish population-based prospective cohort. Dietary data were collected using a modified diet history method. National registers were used for outcome ascertainment.

Results: During the mean follow-up of 19.5 years, there were 2,580 stroke cases, 2,840 coronary events, 4,241 atrial fibrillation cases, and 669 aortic stenosis cases. Added sugar intakes above 20 energy percentage were associated with increased risk of coronary events compared to the lowest intake category (HR: 1.39; 95% CI: 1.09–1.78), and increased stroke risk compared to intakes between 7.5 and 10 energy percentage (HR: 1.31; 95% CI: 1.03 and 1.66). Subjects in the lowest intake group for added sugar had the highest risk of atrial fibrillation and aortic stenosis. More than 8 servings/week of sugar-sweetened beverages were associated with increased stroke risk, while ≤2 servings/week of treats were associated with the highest risks of stroke, coronary events and atrial fibrillation.

Conclusion: The results indicate that the associations between different added sugar sources and cardiovascular diseases vary. These findings emphasize the complexity of the studied associations and the importance of considering different added sugar sources when investigating health outcomes.

Association of Consumption of Sugar-Sweetened Beverages or Artificially Sweetened Beverages with Mortality: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Sugar-sweetened beverage (SSB) and artificially sweetened beverage (ASB) intakes have been reported to be associated with mortality; however, conclusions have been inconsistent. This review synthesized the evidence on the associations of SSB and ASB intakes with mortality from all causes, cardiovascular disease (CVD), and cancer among all populations (including general, diseased, or occupational populations, etc.). PubMed, EMBASE, Web of Science, Cochrane Library, ProQuest, ClinicalTrials.gov, and the International Clinical Trials Registry Platform were searched up to March 2020. Fifteen studies including 17 cohorts were included in meta-analyses. Each serving (12 fluid ounces or 355 mL) increase in daily SSB consumption was associated with higher risks of all-cause (HR: 1.08; 95% CI: 1.04, 1.12; 11 cohorts with 965,851 participants) and CVD (HR: 1.08; 95% CI: 1.04, 1.12; 13 cohorts with 898,005 participants) mortality. The associations of ASB intakes with all-cause and CVD mortality were J-shaped, and HRs (95% CI) across different doses (0, 1, 1.5, 2, and 2.5 servings/d) were 1.00, 1.01 (0.99, 1.03), 1.04 (1.02, 1.07), 1.08 (1.05, 1.11), and 1.13 (1.09, 1.18) for all-cause mortality and 1.00, 1.01 (0.96, 1.07), 1.07 (1.01, 1.13), 1.15 (1.08, 1.23), and 1.25 (1.14, 1.37) for CVD mortality. No significant association was found for cancer mortality. According to the NutriGrade scoring system, the quality of evidence on the associations of SSB intakes with all-cause and CVD mortality was high, and the quality of evidence on other associations was low to moderate. In summary, higher SSB and ASB intakes were associated with higher risks of all-cause mortality and CVD mortality. Given the limited evidence, future studies should further investigate the association between ASB intakes and cause-specific mortality.

Association of sugar-sweetened beverage and artificially sweetened beverage intakes with mortality: an analysis of US National Health and Nutrition Examination Survey

PURPOSE

Current evidence on the associations between sugar-sweetened beverage (SSB) intakes and mortality is inconsistent, whereas the evidence on artificially sweetened beverages (ASBs) was sparse. We aimed to investigate the associations of SSB and ASB intakes with mortality in a nationally representative sample of US adults.

METHODS

Participants from the National Health and Nutrition Examination Survey (NHANES, 1999-2014; n = 31,402) were linked to the US mortality registry by the end of 2015. SSB and ASB intakes were collected using 24-h dietary recalls. Cox proportional hazard regression models were used to assess the associations of intakes of SSBs, ASBs, and added sugar from SSBs with mortality with adjustment for demographic, lifestyle, comorbidity, and dietary factors.

RESULTS

After a mean follow-up of 7.9 years, 3878 deaths were identified. The multivariate-adjusted hazard ratios (95% confidence intervals) associated with each additional serving/d of SSB were 1.05 (1.01-1.09) for all-cause mortality and 1.11 (1.03-1.21) for heart disease mortality. Hazard ratios (95% confidence intervals) comparing the extreme quintiles of added sugar intakes from SSBs were 1.22 (1.05-1.42) for all-cause mortality and 1.45 (1.06-1.97) for heart disease mortality. No significant relationship was found between SSB intakes and cancer mortality or between high ASB intakes and mortality. Substituting one serving/d of SSB by an equivalent amount of ASBs, unsweetened coffees and teas, and plain water was associated with a 4-7% lower risk of all-cause mortality.

CONCLUSION

Higher SSB intakes were associated with higher risks of all-cause mortality and heart disease mortality. High ASB intakes were not significantly associated with mortality. ASBs, unsweetened coffees and teas, and plain water might be optional alternatives for reducing SSB intakes.

Intake of Sugar-Sweetened and Low-Calorie Sweetened Beverages and Risk of Cardiovascular Disease: A Meta-Analysis and Systematic Review

The long-term associations between the consumption of sugar-sweetened beverages (SSBs) and low-calorie sweetened beverages (LCSBs) with cardiovascular diseases (CVDs) remains inconsistent. To synthesize the evidence, we conducted a meta-analysis of prospective cohort studies published up to 1 December, 2019 on the associations between SSB and LCSB intake and the risk of CVD incidence and mortality. Out of 5301 articles retrieved from our literature search, 11 articles evaluating the consumption of SSBs (16,915 incident CVD cases, 18,042 CVD deaths) and 8 articles evaluating the consumption of LCSBs (18,077 incident CVD cases, 14,114 CVD deaths) were included in the meta-analysis. A 1 serving/d increment of SSBs was associated with an 8% (RR: 1.08; 95% CI: 1.02, 1.14, I2 = 43.0%) and 8% (RR: 1.08; 95% CI: 1.04, 1.13, I2 = 40.6%) higher risk of CVD incidence and CVD mortality, respectively. A 1 serving/d increment of LCSBs was associated with a 7% (RR: 1.07; 95% CI: 1.05, 1.10, I2 = 0.0%) higher risk of CVD incidence. The association between LCSBs and CVD mortality appeared to be nonlinear (P = 0.003 for nonlinearity) with significant associations observed at high intake levels (>2 servings/d). Under an assumption of causality, the consumption of SSBs may be linked to 9.3% (95% CI: 6.6%, 11.9%) of predicted CVD incidence in the USA from 2015 to 2025, among men and nonpregnant women, who were aged 40-79 y in 2015-2016. The habitual consumption of SSBs was associated with a higher risk of CVD morbidity and mortality in a dose-response manner. LCSBs were also associated with a higher risk of these outcomes, however, the interpretation of these findings may be complicated by reverse causation and residual confounding.

Sugar and artificially sweetened beverages and risk of obesity, type 2 diabetes mellitus, hypertension, and all-cause mortality: a dose-response meta-analysis of prospective cohort studies

Although consumption of sugar-sweetened beverages (SSBs) and artificially sweetened beverages (ASBs) has increasingly been linked with obesity, type 2 diabetes mellitus, hypertension, and all-cause mortality, evidence remains conflicted and dose-response meta-analyses of the associations are lacking. We conducted an updated meta-analysis to synthesize the knowledge about their associations and to explore their dose-response relations. We comprehensively searched PubMed, EMBASE, Web of Science, and Open Grey up to September 2019 for prospective cohort studies investigating the associations in adults. Summary relative risks (RRs) and 95% confidence intervals (CIs) were estimated for the dose-response association. Restricted cubic splines were used to evaluate linear/non-linear relations. We included 39 articles in the meta-analysis. For each 250-mL/d increase in SSB and ASB intake, the risk increased by 12% (RR = 1.12, 95% CI 1.05-1.19, I² = 67.7%) and 21% (RR = 1.21, 95% CI 1.09-1.35, I² = 47.2%) for obesity, 19% (RR = 1.19, 95% CI 1.13-1.25, I² = 82.4%) and 15% (RR = 1.15, 95% CI 1.05-1.26, I² = 92.6%) for T2DM, 10% (RR = 1.10, 95% CI 1.06-1.14, I² = 58.4%) and 8% (RR = 1.08, 95% CI 1.06-1.10, I² = 24.3%) for hypertension, and 4% (RR = 1.04, 95% CI 1.01-1.07, I² = 58.0%) and 6% (RR = 1.06, 95% CI 1.02-1.10, I² = 80.8%) for all-cause mortality. For SSBs, restricted cubic splines showed linear associations with risk of obesity (P_{non-linearity} = 0.359), T2DM (P_{non-linearity} = 0.706), hypertension (P_{non-linearity} = 0.510) and all-cause mortality (P_{non-linearity} = 0.259). For ASBs, we found linear associations with risk of obesity (P_{non-linearity} = 0.299) and T2DM (P_{non-linearity} = 0.847) and non-linear associations with hypertension (P_{non-linearity} = 0.019) and all-cause mortality (P_{non-linearity} = 0.048). Increased consumption of SSBs and ASBs is associated with risk of obesity, T2DM, hypertension, and all-cause mortality. However, the results should be interpreted cautiously because the present analyses were based on only cohort but not intervention studies.

The associations of sugar-sweetened, artificially sweetened and naturally sweet juices with all-cause mortality in 198,285 UK Biobank participants: a prospective cohort study

BACKGROUND

Recent efforts to address the obesity epidemic have focused on sugar consumption, especially sugar-sweetened beverages. However, sugar takes many forms, is only one contributor to overall energy consumption and is correlated with other health-related lifestyle factors. The objective was to investigate the associations with all-cause mortality of sugar- and artificially sweetened beverages and naturally sweet juices.

METHODS

Setting: UK Biobank, UK. Participants joined the UK Biobank study from 2006 to 2010 and were followed up until 2016; 198,285 men and women aged 40-69 years were eligible for this study (40% of the UK Biobank), of whom 3166 (1.6%) died over a mean of 7 years follow-up.

DESIGN

prospective population-based cohort study. Exposure variables: dietary consumption of sugar-sweetened beverages, artificially sweetened beverages, naturally sweet juices (100% fruit/vegetable juices) and total sugar intake, self-reported via 24-h dietary assessment tool completed between 2009 and 2012.

MAIN OUTCOME

all-cause mortality. Cox regression analyses were used to study the association between the daily intake of the above beverages and all-cause mortality. Models were adjusted for sociodemographic, economic, lifestyle and dietary confounders.

RESULTS

Total energy intake, total sugar intake and percentage of energy derived from sugar were comparable among participants who consumed > 2/day sugar-sweetened beverages and > 2/day fruit/vegetable juices (10,221 kJ/day versus 10,381 kJ/day; 183 g versus 190 g; 30.6% versus 31.0%). All-cause mortality was associated with total sugar intake (highest quintile adj. HR 1.28, 95% CI 1.06-1.55) and intake of sugar-sweetened beverages (> 2/day adj. HR 1.84, 95% CI 1.42-2.37) and remained so in sensitivity analyses. An association between artificially sweetened beverage intake and mortality did not persist after excluding deaths in the first 2 years of follow-up (landmark analysis) nor after excluding participants with recent weight loss. Furthermore, the inverse association between fruit/vegetable juice intake and mortality did not persist after additional adjustment for a diet quality score.

CONCLUSIONS

Higher mortality is associated with sugar-sweetened beverages specifically. The lack of an adverse association with fruit/vegetable juices suggests that source of sugar may be important and the association with artificially sweetened beverage may reflect reverse causation.

A Sweet Connection? Fructose's Role in Hepatocellular Carcinoma

Hepatocellular carcinoma is one of few cancer types that continues to grow in incidence and mortality worldwide. With the alarming increase in diabetes and obesity rates, the higher rates of hepatocellular carcinoma are a result of underlying non-alcoholic fatty liver disease. Many have attributed disease progression to an excess consumption of fructose sugar. Fructose has known toxic effects on the liver, including increased fatty acid production, increased oxidative stress, and insulin resistance. These effects have been linked to non-alcoholic fatty liver (NAFLD) disease and a progression to non-alcoholic steatohepatitis (NASH). While the literature suggests fructose may enhance liver cancer progression, the precise mechanisms in which fructose induces tumor formation remains largely unclear. In this review, we summarize the current understanding of fructose metabolism in liver disease and liver tumor development. Furthermore, we consider the latest knowledge of cancer cell metabolism and speculate on additional mechanisms of fructose metabolism in hepatocellular carcinoma.

Relation of Total Sugars, Sucrose, Fructose, and Added Sugars With the Risk of Cardiovascular Disease: A Systematic Review and Dose-Response Meta-analysis of Prospective Cohort Studies

OBJECTIVE

To determine the association of total and added fructose-containing sugars on cardiovascular (CVD) incidence and mortality.

METHODS

MEDLINE, EMBASE and Cochrane Library were searched from January 1, 1980, to July 31, 2018. Prospective cohort studies assessing the association of reported intakes of total, sucrose, fructose and added sugars with CVD incidence and mortality in individuals free from disease at baseline were included. Risk estimates were pooled using the inverse variance method, and dose-response analysis was modeled.

RESULTS

Eligibility criteria were met by 24 prospective cohort comparisons (624,128 unique individuals; 11,856 CVD incidence cases and 12,224 CVD mortality cases). Total sugars, sucrose, and fructose were not associated with CVD incidence. Total sugars (risk ratio, 1.09 [95% confidence interval, 1.02 to 1.17]) and fructose (1.08 [1.01 to 1.15]) showed a harmful association for CVD mortality, there was no association for added sugars and a beneficial association for sucrose (0.94 [0.89 to 0.99]). Dose-response analyses showed a beneficial linear dose-response gradient for sucrose and nonlinear dose-response thresholds for harm for total sugars (133 grams, 26% energy), fructose (58 grams, 11% energy) and added sugars (65 grams, 13% energy) in relation to CVD mortality (P<.05). The certainty of the evidence using GRADE was very low for CVD incidence and low for CVD mortality for all sugar types.

CONCLUSION

Current evidence supports a threshold of harm for intakes of total sugars, added sugars, and fructose at higher exposures and lack of harm for sucrose independent of food form for CVD mortality. Further research of different food sources of sugars is needed to define better the relationship between sugars and CVD. REGISTRATION: clinicaltrials.gov, NCT01608620.

Consumption of Ultra-Processed Foods and Mortality: A National Prospective Cohort in Spain

OBJECTIVE

To assess the prospective association between ultra-processed food consumption and all-cause mortality and to examine the effect of theoretical iso-caloric non-processed foods substitution.

PATIENTS AND METHODS

A population-based cohort of 11,898 individuals (mean age 46.9 years, and 50.5% women) were selected from the ENRICA study, a representative sample of the noninstitutionalized Spanish population. Dietary information was collected by a validated computer-based dietary history and categorized according to their degree of processing using NOVA classification. Total mortality was obtained from the National Death Index. Follow-up lasted from baseline (2008-2010) to mortality date or December 31^th, 2016, whichever was first. The association between quartiles of consumption of ultra-processed food and mortality was analyzed by Cox models adjusted for the main confounders. Restricted cubic-splines were used to assess dose-response relationships when using iso-caloric substitutions.

RESULTS

Average consumption of ultra-processed food was 385 g/d (24.4% of the total energy intake). After a mean follow-up of 7.7 years (93,599 person-years), 440 deaths occurred. The hazard ratio (and 95% CI) for mortality in the highest versus the lowest quartile of ultra-processed food consumption was 1.44 (95% CI, 1.01-2.07; P trend=.03) in percent of energy and 1.46 (95% CI, 1.04-2.05; P trend=.03) in grams per day per kilogram. Isocaloric substitution of ultra-processed food with unprocessed or minimally processed foods was associated with a significant nonlinear decrease in mortality.

CONCLUSION

A higher consumption of ultra-processed food was associated with higher mortality in the general population. Furthermore, the theoretical iso-caloric substitution ultra-processed food by unprocessed or minimally processed foods would suppose a reduction of the mortality risk. If confirmed, these findings support the necessity of the development of new nutritional policies and guides at the national and international level.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01133093.

Multiple health and environmental impacts of foods

Dietary choices are a leading global cause of mortality and environmental degradation and threaten the attainability of the UN’s Sustainable Development Goals and the Paris Climate Agreement. To inform decision making and to better identify the multifaceted health and environmental impacts of dietary choices, we describe how consuming 15 different food groups is associated with 5 health outcomes and 5 aspects of environmental degradation. We find that foods associated with improved adult health also often have low environmental impacts, indicating that the same dietary transitions that would lower incidences of noncommunicable diseases would also help meet environmental sustainability targets.

Food choices are shifting globally in ways that are negatively affecting both human health and the environment. Here we consider how consuming an additional serving per day of each of 15 foods is associated with 5 health outcomes in adults and 5 aspects of agriculturally driven environmental degradation. We find that while there is substantial variation in the health outcomes of different foods, foods associated with a larger reduction in disease risk for one health outcome are often associated with larger reductions in disease risk for other health outcomes. Likewise, foods with lower impacts on one metric of environmental harm tend to have lower impacts on others. Additionally, of the foods associated with improved health (whole grain cereals, fruits, vegetables, legumes, nuts, olive oil, and fish), all except fish have among the lowest environmental impacts, and fish has markedly lower impacts than red meats and processed meats. Foods associated with the largest negative environmental impacts—unprocessed and processed red meat—are consistently associated with the largest increases in disease risk. Thus, dietary transitions toward greater consumption of healthier foods would generally improve environmental sustainability, although processed foods high in sugars harm health but can have relatively low environmental impacts. These findings could help consumers, policy makers, and food companies to better understand the multiple health and environmental implications of food choices.

Effect of Losartan and Fish Oil on Plasma IL-6 and Mobility in Older Persons. The ENRGISE Pilot Randomized Clinical Trial

BACKGROUND

Low-grade chronic inflammation, characterized by elevations in plasma Interleukin-6 (IL-6), is an independent risk factor of impaired mobility in older persons. Angiotensin receptor blockers and omega-3 polyunsaturated fatty acids (ω-3) may reduce IL-6 and may potentially improve physical function. To assess the main effects of the angiotensin receptor blocker losartan and ω-3 as fish oil on IL-6 and 400 m walking speed, we conducted the ENRGISE Pilot multicenter randomized clinical trial.

METHODS

The ENRGISE Pilot enrolled participants between April 2016 and June 2017, who participated for 12 months. Participants were aged ≥70 years with mobility impairment, had IL-6 between 2.5 and 30 pg/mL, and were able to walk 400 m at baseline. Participants were randomized in three strata 2 × 2 factorial to: (i) losartan 50-100 mg/d or placebo (n = 43), (ii) fish oil 1,400-2,800 mg/d or placebo (n = 180), and (iii) with both (n = 66).

RESULTS

Two hundred eighty-nine participants were randomized (mean age 78.3 years, 47.4% women, 17.0% black). There was no effect of losartan (difference of means = -0.065 ± 0.116 [SE], 95% confidence interval [CI]: -0.293-0.163, p = .58) or fish oil (-0.020 ± 0.077, 95% CI: -0.171-0.132, p = .80) on the log of IL-6. Similarly, there was no effect of losartan (-0.025 ± 0.026, 95% CI: -0.076-0.026, p = .34) or fish oil (0.010 ± 0.017, 95% CI: -0.025-0.044, p = .58) on walking speed (m/s).

CONCLUSIONS

These results do not support the use of these interventions to prevent mobility loss in older adults at risk of disability with low-grade chronic inflammation.

REGISTRATION

Clinicaltrials.gov NCT02676466.

Review of the scientific evidence used for establishing US policies on added sugars

The 2015 Dietary Guidelines for Americans Advisory Committee has set recommendations to limit added sugars. This action was based on the association between dietary pattern quality scores and chronic disease risk, the results of meta-analyses conducted for the World Health Organization, and data from modeling of dietary patterns for establishing the US Department of Agriculture's Healthy US-Style Eating Patterns. Recommendations provided by the 2015-2020 Dietary Guidelines for Americans were used by the US Food and Drug Administration to establish, for the first time, the mandatory declaration of added sugars and a Daily Value of added sugars for the Nutrition Facts label. This review provides an overview of the scientific evidence considered by the World Health Organization, the 2015-2020 Dietary Guidelines for Americans, and the US Food and Drug Administration for setting recent polices and regulations on added sugars and highlights important issues and inconsistencies in the evaluations and interpretations of the evidence.

Intake of starch and sugars and total and cause-specific mortality in a Japanese community: the Takayama Study

Studies on the intake of different types of carbohydrates and long-term mortality are sparse. We examined the association of starch, total and each type of sugar and free sugars with the risk of total and cause-specific mortality in a cohort of the general population in Japan. Study subjects were 29 079 residents from the Takayama Study, Japan, who responded to a self-administered questionnaire in 1992. Diet was assessed by a validated FFQ at the baseline. Mortality was ascertained during 16 years of follow-up. We noted 2901 deaths (974 cancer related and 775 cardiovascular related) in men and 2438 death (646 cancer related and 903 cardiovascular related) in women. In men, intake of starch was inversely associated with total mortality after controlling for covariates (hazard ratio (HR) for the highest quartile v. lowest quartile: 0·71; 95 % CI 0·60, 0·84; Ptrend &lt; 0·001). Intakes of total sugars, glucose, fructose, sucrose, maltose and free and naturally occurring sugars were significantly positively associated with total mortality in men (HR for the highest v. lowest quartile of total sugar: 1·27; 95 % CI 1·12, 1·45; Ptrend &lt; 0·0001). Similar relations were observed for cardiovascular mortality and non-cancer, non-cardiovascular mortality in men. In women, there was no significant association between any type of carbohydrates and mortality except that intake of free sugars was significantly positively associated with total and non-cancer, non-cardiovascular mortality. Data suggest that the high intake of starch reduces mortality, whereas the high intake of sugars, including glucose, fructose and sucrose, increases mortality in Japanese men.

Perspective: Public Health Nutrition Policies Should Focus on Healthy Eating, Not on Calorie Counting, Even to Decrease Obesity

Calorie-focused policies, such as calorie menu labeling, seem to result in minor shifts toward healthier choices and public health improvement. This paper discusses the (lack of) relations between energy intake and healthy eating and the rationale for shifting the focus of public health nutrition policies to healthier foods and meals. We argue that the benefits of reducing caloric intake from low-quality foods might not result from the calorie reduction but rather from the reduced consumption of low-quality foods. It is better to consume a given number of calories from high-quality foods than a smaller number of calories from low-quality foods. It is not possible to choose a healthy diet solely based on the caloric value of foods because calories are not equal; they differ in nutritional quality according to their source. Foods are more than just a collection of calories and nutrients, and nutrients interact differently when presented as foods. Different subtypes of a macronutrient, although they have the same caloric value, are metabolized and influence health in different ways. For instance, industrial trans fats increase lipogenesis and the risk of heart diseases, whereas monounsaturated fats have the opposite effect. Food processing and cooking methods also influence the nutritional value of foods. Thus, public health nutrition policies should stop encouraging people to focus mainly on calorie counting to fight noncommunicable diseases. Instead, policies should focus on ingredients, dietary sources, and food processing and cooking methods.

Association between added sugar intake and mortality is nonlinear and dependent on sugar source in 2 Swedish population-based prospective cohorts

Background

Although sugar consumption has been associated with several risk factors for cardiometabolic diseases, evidence for harmful long-term effects is lacking. In addition, most studies have focused on sugar-sweetened beverages (SSBs), not sugar per se.

Objective

The aim of this study was to examine the associations between added and free sugar intake, intake of different sugar sources, and mortality risk.

Methods

Two prospective population-based cohorts were examined: the Malmö Diet and Cancer Study (MDCS; n = 24,272), which collected dietary data by combining a food diary, interview, and food-frequency questionnaire (FFQ), and the Northern Swedish Health and Disease Study (NSHDS; n = 24,475), which assessed diet with an FFQ. Sugar intakes defined as both added and free sugar and different sugar sources were examined. The associations with mortality were examined using a multivariable Cox proportional hazards regression.

Results

Higher sugar consumption was associated with a less favorable lifestyle in general. The lowest mortality risk was found with added sugar intakes between 7.5% and 10% of energy (E%) intake in both cohorts. Intakes >20E% were associated with a 30% increased mortality risk, but increased risks were also found at intakes <5E% [23% in the MDCS and 9% (nonsignificant) in the NSHDS]. Similar U-shaped associations were found for both cardiovascular and cancer mortality in the MDCS. By separately analyzing the different sugar sources, the intake of SSBs was positively associated with mortality, whereas the intake of treats was inversely associated.

Conclusions

Our findings indicate that a high sugar intake is associated with an increased mortality risk. However, the risk is also increased among low sugar consumers, although they have a more favorable lifestyle in general. In addition, the associations are dependent on the type of sugar source.

An Evidence Map of Research Linking Dietary Sugars to Potentially Related Health Outcomes

BACKGROUND

Evidence mapping is an emerging tool used to systematically identify, organize, and summarize the quantity, distribution, and characteristics of published studies with the goal of identifying knowledge gaps and future research needs.

OBJECTIVE

The aim of the study was to present an evidence-map database of all published studies that investigated dietary sugars and to select health outcomes for explicating research trends and gaps.

METHODS

To update an evidence-map database previously published in 2013, we performed a literature search in MEDLINE to identify English-language, peer-reviewed human intervention and prospective cohort studies published from January 2013 to December 2016. Abstracts and full-text articles were dual screened on the basis of predefined eligibility criteria. We classified outcomes into 7 health outcome categories that are potentially affected by dietary sugar. Data from the updated evidence-map database were merged with those from the previous database for analysis and charting.

RESULTS

There were 918 sugar and control intervention arms from a total of 298 intervention studies from 1966 to December 2016. A variety of sugar interventions were investigated across the included intervention studies, and it appears that the research interest across all outcome categories (cardiovascular disease risks, diabetes risks, body weight, body composition, appetite, dietary intake, and liver health-related outcomes) sharply increased from 2006. Bubble plots showed research gaps in long-term intervention studies and in intervention studies in patients with diabetes. In contrast, all 25 included cohort studies had long-term follow-up durations and much larger sample sizes than did intervention studies. None of the cohort studies evaluated dietary intake outcomes, and only one cohort study each examined appetite- and liver health-related outcomes.

CONCLUSIONS

The research trends and research gaps have not changed since 2013 when the original evidence-map database was updated. With continuous updating, evidence mapping can facilitate the process of knowledge translation and possibly reduce research waste.

Dietary sugar intake does not pose any risk of bone loss and non-traumatic fracture and is associated with a decrease in all-cause mortality among Chinese elderly: Finding from an 11-year longitudinal study of Mr. and Ms. OS Hong Kong

BACKGROUND

The association of dietary sugar intake and skeletal health remains uncertain in the elderly. We aimed to investigate the association of sugar intake with the bone health and mortality of Chinese elderly.

METHODS

An analysis was conducted through an 11-year longitudinal study (Mr. and Ms. OS Hong Kong). Four thousand Chinese elderly aged 65 and older were recruited from the local community between 2001 and 2003. Sugar intake was assessed at baseline by a validated 329-item Food Frequency Questionnaire and a local sugar database. The bone mineral density (BMD) was examined at baseline and the fourth year follow-up by a dual-energy X-ray absorptiometry. Data on the incidence of non-traumatic fractures (total, hip and osteoporotic sites) and all-cause mortality were collected. The multivariable logistic and Cox regression models were used to test the associations of sugar intake with bone health and all-cause mortality.

RESULTS

No significant association was observed between sugar intakes and BMD changes in the fourth year's follow-up. During a total 34,483 person years' follow-up, we documented 433 non-traumatic fractures and 769 deaths. Although lack of significant association with the incidence of non-traumatic fractures, high added sugar intakes were significantly associated with a low risk of all-cause mortality among the elderly with a hazard ratio of 0.750 (95% CI: 0.590-0.954, P for trend = 0.007) in the highest quintile compared with that in the lowest quintile.

CONCLUSION

The amount of sugar consumed by the Chinese elderly did not pose any risk of bone loss and fracture. Moreover, high sugar intake of the elderly was associated with a low rate of all-cause mortality.

Pathways and mechanisms linking dietary components to cardiometabolic disease: thinking beyond calories

Calories from any food have the potential to increase risk for obesity and cardiometabolic disease because all calories can directly contribute to positive energy balance and fat gain. However, various dietary components or patterns may promote obesity and cardiometabolic disease by additional mechanisms that are not mediated solely by caloric content. Researchers explored this topic at the 2017 CrossFit Foundation Academic Conference 'Diet and Cardiometabolic Health - Beyond Calories', and this paper summarizes the presentations and follow-up discussions. Regarding the health effects of dietary fat, sugar and non-nutritive sweeteners, it is concluded that food-specific saturated fatty acids and sugar-sweetened beverages promote cardiometabolic diseases by mechanisms that are additional to their contribution of calories to positive energy balance and that aspartame does not promote weight gain. The challenges involved in conducting and interpreting clinical nutritional research, which preclude more extensive conclusions, are detailed. Emerging research is presented exploring the possibility that responses to certain dietary components/patterns are influenced by the metabolic status, developmental period or genotype of the individual; by the responsiveness of brain regions associated with reward to food cues; or by the microbiome. More research regarding these potential 'beyond calories' mechanisms may lead to new strategies for attenuating the obesity crisis.

Intakes and sources of dietary sugars and their association with metabolic and inflammatory markers

BACKGROUND & AIMS

Associations of dietary sugars with metabolic and inflammatory markers may vary according to the source of the sugars. The aim of this study was to examine the association of dietary sugars from different sources [beverages (liquids), foods (solids), extrinsic (free) or intrinsic (non-free)] with metabolic and inflammatory markers.

METHODS

Population-based cross-sectional study of adults in the East of England (n = 9678). Sugar intakes were estimated using food frequency questionnaires. Fasting glycated haemoglobin, glucose, insulin, and C-Reactive Protein (CRP) were measured and indices of metabolic risk were derived (homeostatic model of insulin resistance, HOMA-IR and metabolic risk z-score).

RESULTS

In multiple linear regression analyses adjusted for potential confounders including BMI and TEI, sugars from liquids were positively associated with ln-CRP [b-coefficient (95%CI), 0.14 (0.05,0.22) per 10%TEI] and metabolic risk z-score [0.13 (0.07,0.18)]. Free sugars were positively associated with ln-HOMA-IR [0.05 (0.03,0.08)] and metabolic risk z-score [0.09 (0.06,0.12)]. Sugars from solids were not associated with any outcome. Among major dietary contributors to intakes (g/d), sugars in fruit, vegetables, dairy products/egg dishes, cakes/biscuits/confectionary and squash/juice drinks were not associated, but sugar added to tea, coffee, cereal was significantly positively associated with all outcomes. Sugars in 100% juice [0.16 (0.06,0.25) per 10%TEI] and other non-alcoholic beverages [0.13 (0.03,0.23)] were positively associated with metabolic risk z-score.

CONCLUSION

Higher intakes of sugars from non-alcoholic beverages and sugar added to tea, coffee, cereal were associated with glycaemia and inflammatory markers. Sugars from solids were not associated, irrespective of whether they were intrinsic or extrinsic. Positive associations of free sugars were largely explained by contribution of beverages to intake.