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By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
Dr. Feldman reports no financial relationships relevant to this field of study.
SYNOPSIS: Investigators found drinking more soft drinks, both artificially sweetened and sugar-sweetened, is associated with a higher risk of death, cardiovascular illness, and digestive illnesses.
SOURCE: Mullee A, Romaguera D, Pearson-Stuttard J, et al. Association between soft drink consumption and mortality in 10 European countries. JAMA Intern Med 2019; Sep 3. doi: 10.1001/jamainternmed.2019.2478. [Epub ahead of print].
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 In a European study, Mullee et al investigated not only all-cause mortality, but also specific cause. Drawing from eligible participants in the ongoing European Prospective Investigation into Cancer and Nutrition, 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. 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. 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 also was 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. Study strengths included 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. Clinicians are on solid ground informing patients 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.
Financial Disclosure: Internal Medicine Alert’s Physician Editor Stephen Brunton, MD, is a retained consultant for Abbott, Acadia, Allergan, AstraZeneca, Avadel, Boehringer Ingelheim, GlaxoSmithKline, Janssen, Mylan, and Salix; he serves on the speakers bureau of AstraZeneca, Boehringer Ingelheim, Janssen, Lilly, and Novo Nordisk. Peer Reviewer Gerald Roberts, MD; Editor Jonathan Springston; Editor Jason Schneider; Editorial Group Manager Leslie Coplin; and Accreditations Manager Amy M. Johnson, MSN, RN, CPN, report no financial relationships relevant to this field of study.