Artificially sweetened beverages associated with risk of stroke and dementia
Sugar- and Artificially Sweetened Beverages and the Risks of Incident Stroke and Dementia
Literature - Pase MP, Himali JJ, Beiser AS, et al. - Stroke. 2017; published online ahead of printBackground
Sugar- and artificially sweetened beverages may be associated with an increased risk of stroke and dementia [1-4]. In this study, the association between sugar- or artificially sweetened soft drinks and the 10-year risk of incident stroke and dementia was evaluated using prospective data from the Framingham Offspring Cohort (n=3029 completed exam between 1998-2001).
Main results
- The total caloric intake increased with higher consumption of total sugary beverage (e.g. fruit drinks), but not with higher intake of artificially sweetened soft drinks (e.g. diet cola).
- The prevalence of cardiovascular disease and diabetes mellitus decreased with more frequent consumption of total sugary beverages, but increased with higher consumption of artificially sweetened soft drinks.
- Higher cumulative intake of artificially sweetened soft drink was associated with an increased risk of ischemic stroke (correcting for all variables: HR 1.98 [95% CI 1.03-3.78] for >0-6 drinks/wk and 2.59 [95% CI 1.21-5.57) for ≥1 drink per day, both P=0.01). On the contrary, the intake of total sugary beverages and sugar-sweetened soft drinks was not associated with the risks of stroke.
- The daily intake of artificially sweetened soft drinks was associated with an increased risk of both all-cause dementia and Alzheimer dementia (HR dementia 2.47 [95% CI 1.15-5.30], P=0.02 and HR Alzheimer 2.89 [95% CI 1.18-7.07], P=0.02 for ≥1 drink per day when correcting for age, gender, total caloric intake, education, physical activity and smoking), but these associations were no longer significant after additional adjustment for systolic blood pressure, treatment of hypertension, prevalent cardiovascular disease, atrial fibrillation, left ventricular hypertrophy, total cholesterol, HDL-C, prevalent diabetes mellitus, positivity for at least 1 apolipoprotein E ε4 allele and waist-to-hip ratio.
- After excluding individuals with prevalent diabetes mellitus, the daily intake of artificially sweetened beverages (versus no intake) remained a significant predictor of both incident all-cause dementia and Alzheimer dementia, suggesting that diabetes mellitus is a partial mediator of the association between artificially sweetened beverage intake and incident dementia.
- After excluding individuals with prevalent hypertension, the association between artificially sweetened beverage intake and incident all-stroke was attenuated.
Conclusion
Artificially sweetened soft drink consumption was associated with an increased 10-year risk of stroke and dementia in prospective data from the Framingham Offspring Cohort, whereas no such association was identified with sugar-sweetened beverages.
Editorial comment
In their editorial article [5], Wersching, Gardener, and Sacco note that the fact that the intake of sugar-sweetened beverages was not associated with stroke or dementia could be due to selection bias, because participants with a high and long-term consumption of such products may have had a very high cardiovascular risk and died earlier. On the other hand, they explore the possibility of reverse causation leading to the association between artificially sweetened beverages and stroke and dementia, since participants at increased risk of vascular events may switch from sugary to diet beverages, with the objective to control their risk factors.
The authors conclude as follows: ‘The work by Pase et al highly encourages further discussion and more research into this question, for even small causal effects would have tremendous effects on public health due to the popularity of both artificial-sweetened beverages and sugar-sweetened consumption. The current body of literature is inconclusive about the causal nature of the associations between artificial-sweetened beverage consumption and risk of stroke, dementia, diabetes mellitus and the metabolic syndrome. The growing number of epidemiological studies showing strong associations between frequent consumption of artificial-sweetened beverages and vascular outcomes, however, suggests that it may not be reasonable to substitute or promote artificial-sweetened beverages as healthier alternatives to sugar-sweetened beverages. Both sugar-sweetened and artificially sweetened soft drinks may be hard on the brain.’
References
1. Pase MP, Beiser A, Enserro D, et al. Association of ideal cardiovascular health with vascular brain injury and incident dementia. Stroke. 2016;47:1201–1206.
2. Gorelick PB, Scuteri A, Black SE, et al; American Heart Association Stroke Council, Council on Epidemiology and Prevention, Council on Cardiovascular Nursing, Council on Cardiovascular Radiology and Intervention, and Council on Cardiovascular Surgery and Anesthesia. Vascular contributions to cognitive impairment and dementia: a statement for healthcare professionals from the american heart association/american stroke association. Stroke.2011;42:2672–2713.
3. Bernstein AM, de Koning L, Flint AJ, et al. Soda consumption and the risk of stroke in men and women. Am J Clin Nutr. 2012;95:1190–1199.
4. Gardener H, Rundek T, Markert M, et al. Diet soft drink consumption is associated with an increased risk of vascular events in the Northern Manhattan Study. J Gen Intern Med. 2012;27:1120–1126.
5. Wersching H, Gardener H, Sacco RL. Sugar-Sweetened and Artificially Sweetened Beverages in Relation to Stroke and Dementia: Are Soft Drinks Hard on the Brain? Stroke. 2017; published online ahead of print
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