Sugar-sweetened beverages and risk of obesity and type 2 diabetes: Epidemiologic evidence
Introduction
In recent decades the world has seen an unprecedented rise in the prevalence of overweight and obesity as global shifts in diet and lifestyle increasingly promote positive energy balance. The World Health Organization's latest projections indicate that globally in 2005 approximately 1.6 billion adults were overweight (BMI ≥ 25 kg/m2) and at least 400 million were obese (BMI ≥ 30 kg/m2), numbers which are projected to reach 2.3 billion and 700 million, by 2015 [1]. The percentage of overweight and obese adults in the US increased from 47% and 15% respectively in the late 1970's to over 66% and 33% in 2005–2006, with the greatest proportion of increase observed in Non-Hispanic black and Mexican–American women [2]. Of particular concern is the magnitude of increase occurring among children and adolescents. According to national survey data over the past 3 decades, the prevalence of obesity (sex- and age-specific BMI > 95th percentile), has more than doubled across all age groups and is currently 12.4% in those aged 2–5 years, 17% in those aged 6–11 years and 17.6% in those aged 12–19 years [3] (Fig. 1). These estimates are well above the objectives set for Healthy People 2010, which aim to reduce obesity prevalence to less than 15% [4]. Similar trajectories of increase are being seen across the globe to varying degrees depending on country, region and stage of epidemiologic transition, as many lower-income countries become increasingly urbanized [5], [6]. A recent pooling analysis from 106 countries indicates that overweight and obesity are indeed significant and increasing public health challenges in most regions of the world including India, China, South East Asia, the Pacific Islands, Latin America, the Middle Eastern crescent, and sub-Saharan Africa [7]. The implications of obesity are far reaching, from both a health and economic standpoint. Excess bodyweight is the sixth most important risk factor contributing to the overall global burden of disease [8]. Epidemiologic studies indicate that overweight and obesity are important risk factors for type 2 diabetes (T2DM), cardiovascular disease (CVD), several cancers and premature death [8]. In the US, health care costs attributable to obesity were estimated at $147 billion per year by 2008 [9]. Such excess costs could have serious repercussions for developing countries which must manage co-existing chronic and infectious disease.
One of the most well established risk factors for T2DM is increased adiposity, particularly around the central depots. Examination of temporal trends in the US shows a 10-year lag between the upsurge of obesity and rising rates of T2DM [10]. Nationally representative data from the US show that T2DM increased from 5.3% between 1976–1980 to 12.6% three decades later [9], [11], [12]. Paralleling the global trends in obesity prevalence, T2DM has also emerged as a global public health concern. The International Diabetes Federation (IDF) estimated that in 2007, over 240 million people had T2DM worldwide and this number is projected to reach 380 million by 2025, at which time, 80% of the disease burden will be in low and middle income countries [13]. Asia plays a critical role in this epidemic as it houses some of the worlds' most populous countries and risk of T2DM occurs at a younger age and lower BMI among individuals of Asian ancestry, compared to other ethnicities [5]. Certain Pacific Island populations are already facing prevalence rates as high as 40% [14]. In the past, T2DM prevalence in sub-Saharan Africa was considered negligible. However, with 70% of the population expected to reside in urban areas by 2025, T2DM and other chronic diseases are rising rapidly [15]. In 2007, the IDF estimated that 10.4 million people were living with T2DM in sub-Saharan Africa; a figure expected to reach 18.7 million by 2025, representing an 80% increase [13].
Against a backdrop of a worldwide pandemic of obesity and related chronic diseases, identification of modifiable risk factors for prevention efforts is paramount. For example the American Heart Association recently released a scientific statement recommending reductions in added sugars intake to no more than 100–150 kcal per day for most American women and men respectively, as a means of reducing cardiovascular disease (CVD) risk [16]. The statement identified sugar-sweetened beverages (SSB) as the primary source of added sugars in the American diet. SSBs which include the full spectrum of soft drinks, fruit drinks, energy and vitamin water drinks are comprised of naturally derived caloric sweeteners such as sucrose, HFCS or fruit-juice concentrates, all of which have similar metabolic effects. Indeed a number of large scale epidemiological studies have found consistent positive associations between SSB consumption and long-term weight gain and risk of chronic diseases including metabolic syndrome (MetSyn), T2DM and CHD. SSB consumption is thought to lead to weight gain because of the high added sugars content and low satiety of these beverages and incomplete compensation for total energy at subsequent meals following intake of liquid calories [17]. In addition, because of their high amounts of rapidly absorbable carbohydrates such as sucrose or high-fructose corn syrup (HFCS), coupled with the large quantities often consumed, SSB's may increase risk of T2DM independent of obesity as a potential contributor to a high dietary glycemic load (GL) leading to inflammation, insulin resistance, and impaired beta-cell function [18], [19], [20]. Fructose from any sugar or HFCS may further increase CVD risk by promoting dyslipidemia and deposition of visceral fat, possibly due to increased hepatic de novo lipogenesis and hypertension due to hyperuricemia [14], [21], [22]. Here we discuss temporal trends in SSB intake, the epidemiological evidence linking SSB's to increased risk for developing obesity, T2DM and MetSyn, other metabolic diseases and overall cardiovascular risk as well as consideration of potential underlying biological mechanisms.
Section snippets
Trends of SSB intake
Time-trend data over the past 3 decades has shown a close parallel between the obesity epidemic and rising levels of SSB consumption. Nationally representative estimates from the US show a steady increase in per capita calories from SSBs in both children and adults starting from the mid 1960's (Fig. 2) [23]. At the same time, a decrease in calories consumed from milk, has taken place, particularly among children, while juice consumption has remained relatively stable across all age groups. The
Cross-sectional studies
A large number of cross-sectional studies have been conducted to evaluate the association between SSB intake and overweight or obesity. Malik et al. reviewed the literature until 2006 [32]. Of the 13 studies conducted among children and adolescents, the majority found significant positive associations or trends towards a positive association. Larger studies tended to show stronger more consistent results. For example findings from the Growing Up Today study (GUTs) which included > 10,000
Obesity
Findings from prospective cohort studies generally confirm those from cross-sectional data in that greater SSB consumption is positively associated with overweight and obesity. Despite a large degree of diversity between studies in terms of outcome assessment, number of participants and duration of follow-up, which can substantially impact ability to detect an effect, previous reviews and meta-analyses have found consistent results in both children and adults [32], [38], [39], [40].
Potential biological mechanisms
SSB consumption is thought to lead to weight gain by virtue of decreased satiety and an incomplete compensatory reduction in energy intake at subsequent meals following intake of liquid calories. On average, one 12-oz serving of SSB contains about 140–150 calories [74]. If these calories are added to the typical US diet without reducing calories from other sources, one SSB per day could lead to a weight gain of 15 lbs over the course of one year. This is supported by evidence from short term
Conclusions and public health implications
The prevalence of obesity and related chronic diseases is rising at unprecedented rates across the globe. Identification of modifiable risk factors is therefore essential to abate this escalating pandemic. Temporal patterns in SSB intake across recent decades have shown a close parallel between the obesity epidemic and rising levels of SSB consumption. Findings from epidemiological studies clearly indicate that regular consumption of SSBs can lead to weight gain and substantially increase risk
References (102)
- et al.
Obesity
Lancet
(Oct 1 2005) Foods contributing to energy intake in the US: data from NHANES III and NHANES 1999–2000
J Food Compos Anal
(2004)- et al.
Sugar-sweetened beverages, serum uric acid, and blood pressure in adolescents
J Pediatr
(Jun 2009) - et al.
Glycemic index, glycemic load, and dietary fiber intake and incidence of type 2 diabetes in younger and middle-aged women
Am J Clin Nutr
(Aug 2004) - et al.
Relation between a diet with a high glycemic load and plasma concentrations of high-sensitivity C-reactive protein in middle-aged women
Am J Clin Nutr
(Mar 2002) - et al.
Gout
Lancet
(2010 Jan 23) - et al.
Changes in beverage intake between 1977 and 2001
Am J Prev Med
(Oct 2004) - et al.
Energy intake from beverages is increasing among Mexican adolescents and adults
J Nutr
(Dec 2008) - et al.
Intake of sugar-sweetened beverages and weight gain: a systematic review
Am J Clin Nutr
(Aug 2006) - et al.
Sugar-sweetened beverages and BMI in children and adolescents: reanalyses of a meta-analysis
Am J Clin Nutr
(Jan 2009)
Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis
Lancet
Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children
J Am Diet Assoc
Is sugar-sweetened beverage consumption associated with increased fatness in children?
Nutrition
Food groups as predictors for short-term weight changes in men and women of the EPIC-Potsdam cohort
J Nutr
Predictors of weight gain in a Mediterranean cohort: the Seguimiento Universidad de Navarra Study 1
Am J Clin Nutr
Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial
Am J Clin Nutr
Consumption of sweetened beverages and intakes of fructose and glucose predict type 2 diabetes occurrence
J Nutr
Dietary pattern, inflammation, and incidence of type 2 diabetes in women
Am J Clin Nutr
Effect of sucrose on inflammatory markers in overweight humans
Am J Clin Nutr
Sweetened beverage consumption and risk of coronary heart disease in women
Am J Clin Nutr
Glycemic load, glycemic index, and carbohydrate intake in relation to risk of cholecystectomy in women
Gastroenterology
Beverage intake, diabetes, and glucose control of adults in America
Ann Epidemiol
Sucrose compared with artificial sweeteners: different effects on ad libitum food intake and body weight after 10 wk of supplementation in overweight subjects
Am J Clin Nutr
Effect of drinking soda sweetened with aspartame or high-fructose corn syrup on food intake and body weight
Am J Clin Nutr
Does the consumption of caloric and non-caloric beverages with a meal affect energy intake?
Appetite
Short-term effects of alcohol consumption on appetite and energy intake
Physiol Behav
Short-term effects of the flavour of drinks on ingestive behaviours in man
Appetite
Effects of milk or water on lunch intake in preschool children
Appetite
The effect of aspartame as part of a multidisciplinary weight-control program on short- and long-term control of body weight
Am J Clin Nutr
The effects of the spontaneous ingestion of particular foods or beverages on the meal pattern and overall nutrient intake of humans
Physiol Behav
A new proposed guidance system for beverage consumption in the United States
Am J Clin Nutr
A prospective study of dietary glycemic load, carbohydrate intake, and risk of coronary heart disease in US women
Am J Clin Nutr
Fructose, weight gain, and the insulin resistance syndrome
Am J Clin Nutr
How bad is fructose?
Am J Clin Nutr
Twenty-four-hour endocrine and metabolic profiles following consumption of high-fructose corn syrup-, sucrose-, fructose-, and glucose-sweetened beverages with meals
Am J Clin Nutr
Endocrine and metabolic effects of consuming beverages sweetened with fructose, glucose, sucrose, or high-fructose corn syrup
Am J Clin Nutr
Potential role of sugar (fructose) in the epidemic of hypertension, obesity and the metabolic syndrome, diabetes, kidney disease, and cardiovascular disease
Am J Clin Nutr
Uric acid: a marker of increased cardiovascular risk
Atherosclerosis
Comparative effects of fructose, aspartame, glucose, and water preloads on calorie and macronutrient intake
Am J Clin Nutr
Prevalence of overweight and obesity in the United States, 1999–2004
JAMA
Endocrine and metabolic effects of consuming fructose- and glucose-sweetened beverages with meals in obese men and women: influence of insulin resistance on plasma triglyceride responses
J Clin Endocrinol Metab
Diabetes in Asia: epidemiology, risk factors, and pathophysiology
JAMA
What can public health nutritionists do to curb the epidemic of nutrition-related noncommunicable disease?
Nutr Rev
Global burden of obesity in 2005 and projections to 2030
Int J Obes (Lond)
Annual medical spending attributable to obesity: payer- and service-specific estimates
Health Aff (Millwood)
The emerging pandemic of obesity and diabetes: are we doing enough to prevent a disaster?
Int J Clin Pract
Trends in the prevalence and ratio of diagnosed to undiagnosed diabetes according to obesity levels in the U.S.
Diabetes Care
Full accounting of diabetes and pre-diabetes in the U.S. population in 1988–1994 and 2005–2006
Diabetes Care
Cited by (630)
Reducing sugar intake through chronic swimming training: Exploring palatability changes and central vasopressin mechanisms
2024, Pharmacology Biochemistry and BehaviorUltra-processed Food Intake and Risk of Type 2 Diabetes in Korean Adults
2024, Journal of NutritionChildhood Sugar-Sweetened Beverage Consumption: an Agent-Based Model of Context-Specific Reduction Efforts
2023, American Journal of Preventive MedicineRole of diet and exercise in aging, Alzheimer's disease, and other chronic diseases
2023, Ageing Research ReviewsSweet taste preference is associated with greater hypothalamic response to glucose and longitudinal weight gain
2023, Physiology and BehaviorEstimating the unintended impact of the North American free trade agreement on U.S. public heath
2023, Social Science and Medicine