Sugar-Sweetened Beverages
and Health
CIA-Harvard Menus of Change®
National Leadership Summit
June 10, 2014 Cambridge, MA General Session IV
Walter C. Willett, MD, DrPH
Department of Nutrition
Harvard School of Public Health
What are Sugar-Sweetened Beverages?
Examples
Sodas Fruit Drinks Energy Drinks
Coke ®
Pepsi ®
Mountain Dew ®
Orange Soda
Root Beer
Sprite ®
7-Up ®
Capri Sun ®
Fruitopia ®
Hawaiian Punch ®
Hi-C ®
Kool-Aid ®
Minute Maid ®
Snapple juices ®
Adrenaline Rush ®
Full Throttle ®
MDX ®
No Fear ®
RockStar ®
EnergyVault ®
Sports Drinks
Gatorade ®
Powerade ®
SSBs Ingredients
• Energy: 12-14 kcal/ounce or ~120-150 kcal/12 ounce can
• Sugars: 3.1-3.6 g/ounce (~10 tsp/12 ounce can)
Sweetened by
US: High fructose corn syrups
(55% fructose and 42% glucose)
Europe: Sucrose
(50% fructose and 50% glucose)
Sugar-Sweetened Beverage Consumption
High glycemic load
Postprandial
hyperglycemia &
hyperinsulinemia
Energy in
liquid form
Displacement of more
satiating foods
Passive calorie
overconsumption
when drinking to
satisfy thirst
Increased
hunger
Increased energy
intake
Obesity
Metabolic Syndrome (low HDLC, high triglyceride,
hypertension, hyperglycemia
coagulopathy, chronic inflammation)
Diabetes CHD
Alteration of taste
preferences
Sugar
Increased intake of sugary
foods; decreased intake of
vegetables, fruits, etc
Lower intake of fiber
micronutrients,
antioxidants and other
phytochemicals
Dental caries
Insulin
resistance
B-cell
dysfunction
Incomplete
calorie
compensation
29.273
Nurses’ Health Study (n=121,700)
Health Professionals Follow-up Study (n=52,000)
Nurses’ Health Study II (n=116,000)
Investigators: Frank Speizer, Bernie Rosner, Meir Stampfer, Graham Colditz, David
Hunter, JoAnn Manson, Sue Hankinson, Eric Rimm, Edward Giovannucci, Alberto
Ascherio, Gary Curhan, Charlie Fuchs, Fran Grodstein, Michelle Holmes, Frank Hu
1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000
Diet Ocs
Smoking
Weight/Ht
Med. Hist.
Diet Diet Diet
Blood
Diet Diet
1986 1988 1990 1992 1994 1996 1998 2000
Diet Diet Diet
Blood
Diet
1989 1991 1993 1995 1997 1999
Diet Diet Diet
0.198R
Nails
Nails
Blood
Sugar-Sweetened Beverages and Weight Gain
in Children and Adults:
A Systematic Review and Meta-Analysis
Malik et al. AJCN 2013
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 91.6%, p = 0.000)
I-V Overall
Ludwig, 2001 (16)
Libuda, 2008, Girls (12)
Laurson, 2008, Girls (15)
Carlson, 2012 (21)
Olsen, 2012 (13)
Mundt, 2006, Girls (9)
Striegal-Moore, 2006 (10)
Berkey, 2004, Girls (17)
Johnson, 2007 (11)
Laska, 2012, Boys (14)
Berkey, 2004, Boys (17)
Study
Viner, 2006 (18)
Laurson, 2008, Boys (15)
Laska, 2012, Girls (14)
Blum, 2005 (7)
Libuda, 2008, Boys (12)
Newby, 2004 (8)
Vanselow, 2009 (19)
Phillips, 2004 (20)
Mundt, 2006, Boys (9)
0.07 (0.01, 0.12)
0.16 (0.15, 0.16)
0.20 (0.10, 0.30)
0.10 (-0.02, 0.22)
0.60 (0.23, 0.97)
0.20 (-0.05, 0.44)
0.26 (-0.03, 0.55)
-0.09 (-0.20, 0.02)
0.04 (0.00, 0.08)
0.03 (-0.01, 0.07)
-0.16 (-0.59, 0.27)
0.25 (0.05, 0.45)
0.04 (0.00, 0.08)
BMI (95% CI)
0.17 (0.16, 0.18)
-0.26 (-0.51, -0.01)
-0.09 (-0.40, 0.22)
-0.08 (-0.30, 0.14)
0.03 (-0.07, 0.13)
-0.12 (-0.59, 0.35)
Change in
0.08 (-0.37, 0.53)
0.18 (0.07, 0.28)
-0.06 (-0.13, 0.01)
100.00
6.86
6.30
1.86
3.41
2.64
6.58
8.29
8.25
1.47
4.29
8.25
(D+L)
8.57
3.19
%
2.41
3.88
6.86
1.27
Weight
1.36
6.64
7.64
0.07 (0.01, 0.12)
0.16 (0.15, 0.16)
0.20 (0.10, 0.30)
0.10 (-0.02, 0.22)
0.60 (0.23, 0.97)
0.20 (-0.05, 0.44)
0.26 (-0.03, 0.55)
-0.09 (-0.20, 0.02)
0.04 (0.00, 0.08)
0.03 (-0.01, 0.07)
-0.16 (-0.59, 0.27)
0.25 (0.05, 0.45)
0.04 (0.00, 0.08)
BMI (95% CI)
0.17 (0.16, 0.18)
-0.26 (-0.51, -0.01)
-0.09 (-0.40, 0.22)
-0.08 (-0.30, 0.14)
0.03 (-0.07, 0.13)
-0.12 (-0.59, 0.35)
Change in
0.08 (-0.37, 0.53)
0.18 (0.07, 0.28)
-0.06 (-0.13, 0.01)
100.00
6.86
6.30
1.86
3.41
2.64
6.58
8.29
8.25
1.47
4.29
8.25
(D+L)
8.57
3.19
%
2.41
3.88
6.86
1.27
Weight
1.36
6.64
7.64
Inverse association Positive association
-0.97 0.00 0.97-0.97
Change in BMI (95% CI) per 1 serving per day increase in SSB during the time period specified in each study, from prospective cohort studies in children
Children: All Cohort Studies
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 74.6%, p = 0.003)
Sichieri, 2008 (62)
I-V Overall
Study
Ebbeling, 2006 (63)
Ebbeling, 2012 (64)
de Ruyter, 2012 (65)
James, 2004 (61)
-0.17 (-0.39, 0.05)
0.10 (-0.06, 0.26)
-0.12 (-0.22, -0.02)
Difference, BMI (95% CI)
-0.14 (-0.54, 0.26)
-0.57 (-1.12, -0.02)
-0.36 (-0.55, -0.17)
-0.10 (-0.29, 0.09)
Weighted Mean
100.00
25.64
%
(D+L)
14.88
10.23
24.63
24.62
Weight
-0.17 (-0.39, 0.05)
0.10 (-0.06, 0.26)
-0.12 (-0.22, -0.02)
Difference, BMI (95% CI)
-0.14 (-0.54, 0.26)
-0.57 (-1.12, -0.02)
-0.36 (-0.55, -0.17)
-0.10 (-0.29, 0.09)
Weighted Mean
100.00
25.64
%
(D+L)
14.88
10.23
24.63
24.62
Weight
intervention reduces weight intervention increases weight
0.00-1.12 1.12
Children: RCTs
Weighted mean difference in BMI change (95% CI) between intervention and control regimens from RCT’s in children. Interventions evaluated the effect of reducing SSB.
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 70.2%, p = 0.001)
Study
French, 1994, Women (23)
Palmer, 2008 (25)
Barone Gibbs, 2012 (27)
Chen, 2009 (26)
Mozaffarian, 2011 (29)
French, 1994, Men (23)
I-V Overall
Stookey, 2008 (28)
Nooyens, 2005 (24)
0.22 (0.09, 0.34)
weight, kg (95% CI)
0.13 (-0.18, 0.44)
0.17 (0.03, 0.32)
2.12 (0.78, 3.46)
1.09 (0.46, 1.72)
0.11 (0.09, 0.13)
0.17 (-0.11, 0.45)
1 year change in
0.12 (0.10, 0.14)
0.60 (0.17, 1.04)
0.12 (0.00, 0.24)
100.00
(D+L)
10.00
19.80
0.83
3.39
26.79
%
11.36
Weight
6.26
21.57
0.22 (0.09, 0.34)
weight, kg (95% CI)
0.13 (-0.18, 0.44)
0.17 (0.03, 0.32)
2.12 (0.78, 3.46)
1.09 (0.46, 1.72)
0.11 (0.09, 0.13)
0.17 (-0.11, 0.45)
1 year change in
0.12 (0.10, 0.14)
0.60 (0.17, 1.04)
0.12 (0.00, 0.24)
100.00
(D+L)
10.00
19.80
0.83
3.39
26.79
%
11.36
Weight
6.26
21.57
Inverse association Positive association
0.00-3.46 3.46
Adults: Change vs. Change
1-year change in weight (kg) per 1 serving per day increase in SSB, from prospective cohort studies in adults using a change vs. change analysis strategy
Changes in Food and Beverage Consumption and Weight
Changes Every 4 Years, According to Study Cohort
(Mozaffarian D et al., NEJM 2011) 23.059
NOTE: Weights are from random effects analysis
D+L Overall (I-squared = 0.0%, p = 0.780)
Aeberli, 2011 (70)
Maersk, 2012 (68)
Tordoff, 1990, Women (69)
I-V Overall
Reid, 2010 (67)
Reid, 2007 (66)
Tordoff, 1990, Men (69)
Study
0.85 (0.50, 1.20)
0.30 (-1.12, 1.72)
Weighted Mean
0.66 (-2.25, 3.57)
0.72 (0.14, 1.30)
0.85 (0.50, 1.20)
0.43 (-0.84, 1.70)
1.37 (0.38, 2.36)
0.99 (0.41, 1.57)
Difference, kg (95% CI)
100.00
6.09
Weight
1.45
%
36.04
7.62
12.51
36.29
(D+L)
0.85 (0.50, 1.20)
0.30 (-1.12, 1.72)
Weighted Mean
0.66 (-2.25, 3.57)
0.72 (0.14, 1.30)
0.85 (0.50, 1.20)
0.43 (-0.84, 1.70)
1.37 (0.38, 2.36)
0.99 (0.41, 1.57)
Difference, kg (95% CI)
100.00
6.09
Weight
1.45
%
36.04
7.62
12.51
36.29
(D+L)
intervention reduces weight intervention increases weight
0.00-3.57 3.57
Adults: RCTs
Weighted mean difference in weight change (kg) between intervention and control regimens from RCT’s in adults. Interventions evaluated the effect of adding SSB
1.50
1.85
1.061.00
1.39 1.41
1.001.11
0.0
0.5
1.0
1.5
2.0
2.5
<1/mo 1-4/mo 2-6/wk >=1/d
Sugar-sweetened soft drink consumption
Rela
tive R
isk
multivariate adjusted multivariate + BMI
P<0.001 for trend
Regular Soft Drinks & Type 2 Diabetes, NHS2
(Schulze et al. 2004) 25.080
Meta-Analysis of Prospective Studies on Sugar-
Sweetened Beverages and Risk of Type 2 Diabetes
Malik et al. Diabetes Care 2010
RR for Sweetened Beverages & Risk of CHD
0.6
0.8
1
1.2
1.4
<1/mo 1-4/mo 2-6/wk 1- <2/d 2+/d
P=0.004
Re
lati
ve
Ris
k o
f C
HD
Quintiles of Sweetened Beverage
(Fung et al. 2008) 8.124
Adjusted HRs of CVD Mortality by Categories of SSBs Consumption NHANES 1988-2006
Servings of SSBs Consumption Per Week
<1 1 to <3 3 to <7 ≥7
Age-sex-race adjusted HRs
1.00 0.99
(0.70 -1.38)
1.01
(0.73 - 1.38)
1.37
(1.09 - 1.71)
Fully Adjusted*
1.00 1.04
(0.74 - 1.46)
1.05
(0.74 - 1.49)
1.32
(1.04 - 1.66)
* Adjusted for age, sex, race/ethnicity, education, smoking status, alcohol consumption, BMI, physical activity, family history of CVD, Healthy Eating Index, antihypertensive medication use, systolic blood pressure, total cholesterol, and total calorie intake
Conclusions:
Adverse effects of soda/SSB consumption on risks of obesity, diabetes, heart disease, gout, and dental caries well documented
Tide has turned in the US, and soda consumption is declining Big soda, like big tobacco, is looking elsewhere for future growth Nevertheless, big soda still uses every tactic possible to promote
sales in US and obstruct public health progress Food services can play a critical role by offering attractive
alternative beverages
Forshee, RA et al. Am J Clin Nutr 2008
SSB and BMI in Children
Change in BMI per 1 serving/d increase in SSB, during the time period specified for each study
Malik VS et al. Am J Clin Nutr, 2009
SSB and BMI in Children: Re-analysis
Fixed Effects: 0.03 (0.01, 0.04)
SSB and BMI in Children: Re-analysis, Removing Studies that Adjusted for Total Energy
Malik VS et al. Am J Clin Nutr, 2009 Fixed Effects: 0.03 (0.02, 0.05)
RR (95% CI) P trend
High WC 1.09 (1.04, 1.15) <0.001
High Fasting glucose 1.03 (0.95, 1.12) 0.4600
High TG 1.06 (1.01, 1.13) 0.033
High LDL 1.18 (1.02, 1.36) 0.018
Low HDL 1.06 (0.97, 1.16) 0.192
Hypertension 1.06 (1.01, 1.12) 0.023
RR associated with each increase in quartile of SSB consumption
Am J Clin Nutr 2010;92:954–9.
N= 2774, 20 yr follow-up
Drinking caloric beverages increases the risk
of cardiometabolic outcomes in the Coronary Artery
Risk Development in Young Adults (CARDIA) Study
Parallel, 10 wks: Sucrose-rich diet increased postprandial glucose,
insulin, and lipids compared artificial sweeteners in overweight
healthy subjects. Food Nutr Res 2011;55.
Parallel, 10-wks: Sucrose-rich diet increased serum levels of
haptoglobin, transferrin and CRP compared artificial sweetener in
overweight healthy subjects. Am J Clin Nutr 2005;82(2):421-7
Cross-over, 3 wks: SSB (fructose, sucrose) consumed in small to
moderate quantities impaired glucose and lipid metabolism and
promoted inflammation in normal-weight healthy men.
Am J Clin Nutr 2011;94(2):479-85
SSB and Biomarkers:
Evidence from Short Term Trials