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