Consumption of Sugar Sweetened vs. Artificially Sweetened Beverages and Mortality Risk

Previous studies have raised carcinogenic concern on artificial sweeteners. This study compares sugar sweetened beverages to artificially sweetened ones to assess risk of mortality.

Excessive weight gain is highly correlated with the prevalence of type 2 diabetes. And therefore, weight reduction is a strong recommendation for type 2 diabetes prevention and management. This has led to a rise in using low-calorie artificial sweeteners instead of added sugars to limit caloric intake, reduce carbohydrates and facilitate weight loss. The question is, what is the role of artificial sweeteners in people with diabetes? The use of low-caloric sweeteners appears to play an important role in diabetes prevention and management as it promotes a healthier weight; however, there are controversies on the use of artificial sweeteners, such as carcinogenic risks. So, should sugar sweeteners be replaced by artificially sweetened beverages if used in moderation?  A newly published article in April, 2019 discusses the effect of the long-term consumption of sugar-sweetened and artificially sweetened beverages.

Soft drinks, juice drinks, energy drinks and many other drinks on the market contain a high level of added caloric sweeteners. Per the dietary guidelines for Americans on sugar intake, we should consume no more than 10% of total energy from added sugar. In recent years, the intake of artificially sweetened beverages has risen as an alternative to sugar sweeteners to decrease caloric intake. Some studies have associated an increased risk of death associated with artificially sweetened beverages; however, other factors may have led to those results and more studies are needed to confirm. This study was designed to investigate the associations of sugar sweetened beverages and artificially sweetened beverages with total and cause-specific mortality in 2 large cohorts of US women and men who are middle-aged at baseline with repeated measurements of diet over 28 to 34 years.

This study analysis conducted 2 ongoing prospective cohort studies: the Nurses Health Study (NHS), initiated in 1976, which included 121,700 women ages 30-55 years at trial initiation; and the Health Professionals Follow-up Study (HPFS) which began in 1986 and included 52,529 men ages 40 to 75 at entry. After exclusion, 80,647 women and 37,716 men remained in the study. Total sugar sweetened beverages (SSBs) included caffeinated colas, caffeine-free colas and other carbonated sugar-sweetened beverages. Fruit juice was not considered an SSBs. Artificially sweetened beverages (ASBs) included caffeinated, caffeine free and non-carbonated low-calorie or diet beverages.

During 34 years of follow up, 23,432 deaths occurred in the NHS group, where 4139 deaths were CVD related and 8318 deaths linked to cancer. During the 28 years of follow up in the HPFS group, 13,004 deaths occurred with 3757 CVD deaths and 4062 linked to cancer.  SSB consumption was associated with younger men and women, less physically active, less likely to take a multivitamin, more likely to smoke, had a higher intake of total energy, red and processed meat, and glycemic load with a lower intake of vegetables and whole grains, compared to those who consumed little SSB. ASBs intake was associated with younger consumers, have a greater BMI, overweight, lower glycemic load and have hypertension. Results showed that SSBs increased the risk of total mortality in both cohorts after adjusting for diet and lifestyle factors. Compared with those who have consumed SSBs less than once per month, it appears that women that had 2 or more servings of SSBs per day had a 63% higher risk of death (HR, 1.63; 95% CI, 1.52-1.75) and men had a 29% higher risk of death (HR, 1.29; 95% CI, 1.15-1.44). In addition to that, SSB was also correlated with an increased risk of CVD mortality. There was also a positive association between SSB and risk of cancer mortality. High intake of ASBs (4 or more servings/day) also was associated with CVD mortality that was statistically significant in women but was not associated with cancer mortality in either cohort.

In conclusion, SSBs may be associated with risk of mortality by increasing cardiometabolic and chronic disease, weight gain, higher risk of hypertension, diabetes, CHD and stroke. ASB intake was not correlated with mortality in the HPFS but associated with CVD mortality in the NHS at only intakes of 4 or more servings/day, and an association with mortality was only found in those who were overweight or had high levels of physical activity in stratified analysis. In other words, there was a noted greater risk with SSBs in terms of risk of mortality that showed association with the dose. ASBs were associated with total and CVD mortality mostly among women but further studies are required to confirm. Replacing SSBs with ASBs seemed to moderately decrease risk of mortality.

Practice Pearls:

• High SSB intake increased the risk of death in women by 63%, and 29% higher risk of death in men.
• The findings of this study appear to support recommendations to limit SSB intake and consume ASBs in moderation to improve health, as it seems to moderately decrease risk of mortality.
• ASB was associated with CVD mortality in the NHS only at intakes of 4 or more servings/day.

References:

Malik VS, Li Y, Pan A, et al. Long-Term Consumption of Sugar-Sweetened and Artificially Sweetened Beverages and Risk of Mortality in US Adults. Circulation. 2019;139:2113–2125. DOI: 10.1161/CIRCULATIONAHA.118.037401

Johnston CA, Stevens B, Foreyt JP. The Role of Low-Calorie Sweeteners in Diabetes. European Endocrinology, 2013;9(2):96-8

U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. https://health.gov/dietaryguidelines/2015/guidelines/.

Tandel KR. Sugar Substitute: Health controversy over perceived benefits. J Pharmacol Pharmacother. 2011 Oct-Dec; 2(4): 236–243. doi: 10.4103/0976-500X.85936

Marian Ayad, BSPharm, BCPS, PharmD candidate, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences