Sugar-sweetened beverage consumption associated with adverse changes in HDL-c and triglycerides
Beverage Consumption and Longitudinal Changes in Lipoprotein Concentrations and Incident Dyslipidemia in US Adults: The Framingham Heart Study Clinical importance of urinary sodium excretion in acute heart failure
Literature - Haslam DE, Peloso GM, Herman MA et al., - J Am Heart Assoc. 2020;9(5):e014083. doi: 10.1161/JAHA.119.014083.Introduction and methods
Sugar-sweetened beverages (SSBs), such as sodas, fruit-flavored drinks, sports drinks, and presweetened coffees and teas are a major source of sugar in the diet of US adults and contribute to excess energy intake [1]. Observational studies suggest that there is an association between added sugar intake and CVD risk [2-4]. Furthermore, intervention trials in animals and humans suggest that consumption of large amounts of sugar can induce dyslipidemia [5-7]. 100% fruit juices (FJ) and low-calorie sweetened beverages (LCSB) are used as alternative beverages to SSBs. Randomized controlled trials and observational studies have examined the association between LCSB [8-10] and FJ [11,12] consumption and CVD, but evidence is mixed. This study aimed to examine the association of SSB, LCSB and FJ consumption with longitudinal changes in concentrations of triglyceride, LDL-c, HDL-c and non-HDL-c concentrations.
The current study used data from the Framingham Offspring Study (FOS, mean age 64.8±9.8 years) [13] and Generation Three (GEN3, mean age 40.3±8.8 years) [14] cohorts. Mean follow-up was 12.5 years. In each cohort, participants underwent physical examination and standard laboratory tests. Participants provided information about their diet, lifestyle, medical history and demographics via standard questionnaires. HDL-c, triglyceride and total cholesterol (TC) concentrations were measured in fasting blood samples. LDL-c concentrations were calculated according to the Friedewald equation (LDL-c=TG-HDL-c-triglyceride/5). The effect of recent and cumulative beverage intake on development of dyslipidemia was examined using data from the FOS cohort at examinations 5 (1991-1995), 6(1995-1998), 7 (1998-2001) 9 (2005-2008) and 9 (2011-2014). Dyslipidemia was defined as LDL-c concentrations ≥160 mg/dL or use of LDL-c-lowering medications; HDL-c concentrations<40 mg/dL in men or <50 mg/dL in women; triglyceride concentrations ≥175 mg/dL; and non–HDL-c concentrations ≥190 mg/dL or use of LDL-c-lowering medications. Beverage intakes were grouped into 5 intake categories: <1 serving (12 fl oz for SSB and LCSB and 8 fl oz for FJ) per month, 1-4 servings per month, 1-2 servings per week, 3-7 servings per week, >1 serving per day. Recent beverage intake was defined as intake at one examination before development of dyslipidemia and cumulative beverage intake as the average beverage intake during the period before development of dyslipidemia.
Main results
- After multivariable adjustment, participants in the highest category of SSB intake (>1 serving per day) had a 1.6 mg/dL lower mean 4-year change in HDL-c concentrations and a 4.4 mg/dL higher mean 4-year change in triglyceride concentrations compared to those in the lowest category of SSB intake (<1 serving per month) (β±standard error (SE):-1.6±0.4 mg/dL, P for trend <0.0001 for HDL-c, and β±SE:-4.4±2.2 mg/dL, P for trend=0.003 for triglyceride).
- Participants in the highest category of LCSB intake had a 0.7 mg/dL lower mean 4-year change in HDL-c concentrations than those in the lowest intake category (β±SE:-0.7±0.2 mg/dL, P for trend=0.001).
- The highest category of recent SSB consumers had 98% higher incidence of low HDL-c and 53% higher incidence of high triglyceride compared to those in the lowest category of SSB intake (HR 1.98, 95%CI 1.20-3.28, P for trend=0.01 for HDL-c and HR 1.53, 95%CI 1.01-2.31, P for trend=0.004 for triglyceride). For cumulative SSB intake, the risk was attenuated to nonsignificant for incidence of low HDL-c and high triglyceride.
- The highest category of recent LCSB consumers had a 40% higher incidence of high non-HDL-c and 27% higher incidence of high LDL-c compared with the lowest category of LCSB consumers (HR 1.40, 95%CI, 1.17-1.69, P for trend=0.0002 for non-HDL-c, and HR 1.27, 95%CI 1.05-1.53, P for trend=0.01 for LDL-c). For cumulative LCSB intake, these associations were attenuated to nonsignificant.
- No significant associations were found between risk of dyslipidemia and intake of FJ.
Conclusion
SSB consumption was associated with adverse changes in HDL-c and triglyceride. High recent SSB intake was associated with higher incidence of low HDL-c and high triglycerides and high recent LCSB consumption was associated with higher incidence of high non-HDL-c and high LDL-c compared to low consumption of these beverages. No increased risk was found for cumulative SSB and LCSB intake and no significant associations were found between risk of dyslipidemia and intake of FJ.
Editorial comment
Daily intake of added sugars should not exceed 10% of the total daily calories according to the 2015-2020 Dietary Guidelines for Americans [15]. Although SSB consumption has decreased in the US during the past decade, SSB consumption remains high [16,17]. Kuklina and Park note in their editorial comment [18] that there is substantial evidence available that supports limiting SSB intake for health benefits including reduced risk of obesity, T2DM and CVD [19]. The current study of Haslam et al. provides evidence on the adverse effects of SSBs on lipid profile. Regular SSB consumption was associated with a decrease in HDL-c and increase in triglycerides and regular LCSB consumption was associated with an increase in LDL-c and non-HDL-c compared to low consumption of these beverages. Kuklina and Park note that the sugar content in LCSB can vary from 0 to 9.99g per serving, which complicates the interpretation of results.
No significant associations were found between consumption of FJ and lipid profile. A review article previously reported that the effects of FJ on lipids are inconsistent [20]. Kuklina and Park comment that FJ can be easily overconsumed and can therefore contribute to energy imbalance by increasing the calorie intake [15]. Thus, a limited amount of FJ can be consumed, but whole fruits are a better choice, as FJ has no nutritional benefits over whole fruits [15].
Several factors have been identified as contributors to the consumption of SSBs, such as exposure to advertisements, availability of SSBs in schools or at home, and parental consumption of SSBs [21-24]. A Cochrane review investigated the evidence for environmental interventions to reduce SSB intake [25]. These interventions included consumer labels on SSBs promoting healthier beverages in supermarkets, increasing prices on SSBs in restaurants, stores and fitness centers (compared with other drinks, such as water), and easier access to healthier beverages at home. Kuklina and Park conclude that implementation of interventions to address SSB consumption requires a collaborative and multisectoral approach.
References
1. Rosinger A, Herrick K, Gahche J, Park S. Sugar-Sweetened Beverage Consumption Among U.S. Adults, 2011–2014. NCHS data brief, no 270. Hyattsville, MD: National Center for Health Statistics; 2017.
2. Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R, Hu FB. Added sugar intake and cardiovascular diseases mortality among us adults. JAMA Intern Med. 2014;174:516–524.
3. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J. Dietary sugars intake and cardiovascular health. Circulation. 2009;120:1011–1020.
4. Malik VS. Sugar sweetened beverages and cardiometabolic health. Curr Opin Cardiol. 2017;32:572–579.
5. Herman MA, Samuel VT. The sweet path to metabolic demise: fructose and lipid synthesis. Trends Endocrinol Metab. 2016;27:719–730.
6. Malik VS, Hu FB. Fructose and cardiometabolic health: what the evidence from sugar-sweetened beverages tells US. J Am Coll Cardiol. 2015;66:1615–1624.
7. Hannou SA, Haslam DE, McKeown NM, Herman MA. Fructose metabolism and metabolic disease. J Clin Invest. 2018;128:545–555.
8. Yu Z, Ley SH, Sun Q, Hu FB, Malik VS. Cross-sectional association between sugar-sweetened beverage intake and cardiometabolic biomarkers in US women. Br J Nutr. 2018;119:570–580.
9. Sylvetsky AC, Rother KI. Non-nutritive sweeteners in weight management and chronic disease: a review. Obesity (Silver Spring). 2018;26:635–640.
10. Azad MB, Abou-Setta AM, Chauhan BF, Rabbani R, Lys J, Copstein L, Mann A, Jeyaraman MM, Reid AE, Fiander M, MacKay DS, McGavock J, Wicklow B, Zarychanski R. Nonnutritive sweeteners and cardiometabolic health: a systematic review and meta-analysis of randomized controlled trials and prospective cohort studies. Can Med Assoc J. 2017;189:E929–E939.
11. Auerbach BJ, Dibey S, Vallila-Buchman P, Kratz M, Krieger J. Review of 100% fruit juice and chronic health conditions: implications for sugar-sweetened beverage policy. Adv Nutr. 2018;9:78–85.
12. Guasch-Ferré M, Hu FB. Are Fruit Juices Just As Unhealthy As Sugar-Sweetened Beverages? JAMA Netw Open. 2019;2:e193109.
13. Kannel WB, Feinleib M, McNamara PM, Garrison RJ, Castelli WP. An investigation of coronary heart disease in familiesthe Framingham offspring study. Am J Epidemiol. 1979;110:281–290.
14. Splansky GL, Corey D, Yang Q, Atwood LD, Cupples LA, Benjamin EJ, D’Agostino RB, Fox CS, Larson MG, Murabito JM, O’Donnell CJ, Vasan RS, Wolf PA, Levy D. The third generation cohort of the National Heart, Lung, and Blood Institute’s Framingham Heart Study: design, recruitment, and initial examination. Am J Epidemiol. 2007;165:1328–1335.
15. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2015–2020. 8th ed. Washington, DC: U.S. Government printing office; 2015. Available at: https://health.gov/sites/default/files/2019-09/2015-2020_Dietary_Guidelines.pdf. Accessed February 6, 2020.
16. Bleich SN, Vercammen KA, Koma JW, Li Z. Trends in beverage consumption among children and adults, 2003–2014. Obesity (Silver Spring). 2018;26:432–441.
17. Lundeen EA, Park S, Pan L, Blanck HM. Daily intake of sugar-sweetened beverages among US adults in 9 states, by state and sociodemographic and behavioral characteristics, 2016. Preventing Chronic Disease. 2018;15:E154.
18. Kuklina EV, Park S. Sugar-Sweetened Beverage Consumption and Lipid Profile: More Evidence for Interventions. J Am Heart Assoc. 2020 Mar 3;9(5):e015061.
19. Malik VS, Hu FB. Sugar-sweetened beverages and cardiometabolic health: an update of the evidence. Nutrients. 2019; 11:E1840.
20. Pepin A, Stanhope KL, Imbeault P. Are fruit juices healthier than sugar-sweetened beverages? A review Nutrients. 2019;11:1006.
21. Imoisili OE, Park S, Lundeen EA, Yaroch AL, Blanck HM. Daily adolescent sugar-sweetened beverage intake is associated with select adolescent, not parent, attitudes about limiting sugary drink and junk food intake. Am J Health Promot. 2020;34:76–82.
22. Bogart LM, Elliott MN, Ober AJ, Klein DJ, Hawes-Dawson J, Cowgill BO, Uyeda K, Schuster MA. Home sweet home: parent and home environmental factors in adolescent consumption of sugar-sweetened beverages. Academic Pediatrics. 2017;17:529–536.
23. Harris JL, Romo-Palafox M, Choi Y, Kibwana A. Children’s drink facts 2019. Sales, nutrition, and marketing of children’s drinks. UConn Rudd center for food policy & obesity. 2019. Available at: http://uconnruddcenter.org/files/Pdfs/FACTS2019.pdf. Accessed February 6, 2020.
24. Taber DR, Stevens J, Evenson KR, Ward DS, Poole C, Maciejewski ML, Murray DM, Brownson RC. State policies targeting junk food in schools: racial/ethnic differences in the effect of policy change on soda consumption. Am J Public Health. 2011;101:1769–1775.
25. von Philipsborn P, Stratil JM, Burns J, Busert LK, Pfadenhauer LM, Polus S, Holzapfel C, Hauner H, Rehfuess E. Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health. Cochrane Database Syst Rev. 2019;6:CD012292.