By Ellen Feldman, MD

Altru Health System, Grand Forks, ND

Dr. Feldman reports no financial relationships relevant to this field of study.

SOURCE: Mullee A, et al. Association between soft drink consumption and mortality in 10 European countries. JAMA Intern Med 2019. doi:10.1001/jamainternmed.2019.2478. [Epub ahead of print].

SYNOPSIS: This long-term, large-scale European study finds that higher use of total soft drinks is associated with a higher risk of death; additionally, higher use of artificially sweetened soft drinks is associated with higher risk of death from cardiovascular illness and higher use of sugar-sweetened soft drinks is associated with higher risk of death from digestive illnesses.

EXECUTIVE SUMMARY

  • In a cohort of more than 400,000 people being followed by a multicenter, European study, increased risk for mortality (variable causes) was seen for soft drinks, both artificially and sugar-sweetened.

Are soft drinks bad for health? Results from observational studies based primarily in the United States suggest a link between all-cause mortality and higher consumption of both sugar and artificially sweetened beverages.1,2 However, sugar-sweetened drinks remain the top contributor to added sugar in a typical American diet, with close to half of adults reporting daily consumption.3

Mullee et al present the results of a large-scale European study not only looking into all-cause mortality, but into specific cause as well. Drawing from eligible participants in the ongoing European Prospective Investigation into Cancer and Nutrition (EPIC), a 10-country, population-based, prospective investigation, 451,743 participants were tracked over a mean of 16.4 years. Dietary habits, specifically the rate of consumption of both artificially and sugar-sweetened soft drinks, were evaluated at entrance into the study. Specific causes of death were recorded. Collection of data varied depending on the country; in most cases, dietary assessment was conducted via self-administered questionnaires, although some locations used in-person interviews. Deaths were determined based on local registries or active inquiry.

In an effort to limit confounding conditions, participants with prior diagnoses of cancer, heart disease, stroke, and diabetes were excluded from this investigation population.

One glass of a soft drink was defined as approximately 250 mL. Higher risk of all-cause mortality was found in respondents drinking more than 125 mL daily of artificially sweetened soft drinks and more than 225 mL daily of sugar-sweetened soft drinks, with hazard ratios (HR) peaking above 1.2 with soft drink consumption above 900 mL daily.

When the authors compared two or more glasses of soft drinks daily vs. consumption of less than one glass monthly, clear risks surfaced in three different areas: all-cause mortality, mortality from cardiovascular disease, and mortality from digestive diseases. (See Table 1.)

Table 1. Mortality by Cause and Soft Drink Consumption

 

All-Cause Mortality

Mortality Related
to Cardiovascular Disease

Mortality Related
to Digstive Diseases

Total soft drinks

HR 1.17;

95% CI, 1.11-1.22

(P < 0.001)

HR 1.27

95% CI, 1.14 -1.40

(P < 0.001)

HR 1.50;

95% CI, 1.24-1.81

(P < 0.001)

Sugar-sweetened soft drinks

HR 1.08;

95% CI, 1.01-1.16

(P = 0.004)

HR 1.11,

95% CI, 0.95-1.30

(P = 0.16)

HR 1.59

95% CI, 1.24-2.05

(P < 0.001)

Artifically sweetened soft drinks

HR 1.26

95% CI, 1.16-1.35

(P < 0.001)

HR 1.52

95% CI, 1.30-1.78

(P < 0.001)

HR 0.99

95% CI, 0.65-1.50

(P = 0.78)

HR: hazard ratio; CI: confidence interval

In this study, total soft drink consumption was not associated with overall risk of death from overall cancer, but there was an association with a higher risk of death from colorectal cancer (HR = 1.25). Total soft drink consumption was also associated with a higher risk of Parkinson’s disease mortality (HR = 1.59). Controlling for body mass index did not change results significantly.

As with any observational study, these results must be viewed with caution regarding causality. One of the strengths of the study is the impressively large number of participants and follow-up years, as well as the multiple sites transcending geographical boundaries. Yet, this strength also results in heterogeneity of methods (i.e., dietary recall), possibly leading to some built-in biases and confounding of results.

The clinician is on solid ground informing patients that there is mounting evidence that soft drink consumption of any type (artificially or sugar-sweetened) is linked to earlier death, and that this link is not necessarily related directly to obesity or diabetes. Although drinking an occasional soft drink does not appear to be linked to higher mortality risk, there are clear indications that more regular use is associated with health risks. This is an additional reminder of the importance and benefit of including a dietary assessment in health visits, especially when creating a comprehensive, patient-centered health and wellness plan.

REFERENCES

  1. Malik VS, et al. Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortality in US adults. Circulation 2019;139:2113-2125.
  2. Mossavar-Rahmani Y, et al. Artificially sweetened beverages and stroke, coronary heart disease, and all-cause mortality in the Women’s Health Initiative. Stroke 2019;50:555-562.
  3. Centers for Disease Control and Prevention. Get the facts: Sugar-sweetened beverages and consumption. Feb. 2017. Available at: https://www.cdc.gov/nutrition/data-statistics/sugar-sweetened-beverages-intake.html. Accessed Nov. 12, 2019.