Elsevier

Physiology & Behavior

Volume 100, Issue 1, 26 April 2010, Pages 47-54
Physiology & Behavior

Sugar-sweetened beverages and risk of obesity and type 2 diabetes: Epidemiologic evidence

https://doi.org/10.1016/j.physbeh.2010.01.036Get rights and content

Abstract

In recent decades, temporal patterns in SSB intake have shown a close parallel between the upsurge in obesity and rising levels of SSB consumption. SSBs are beverages that contain added caloric sweeteners such as sucrose, high-fructose corn syrup or fruit-juice concentrates, all of which result in similar metabolic effects. They include the full spectrum of soft drinks, carbonated soft drinks, fruitades, fruit drinks, sports drinks, energy and vitamin water drinks, sweetened iced tea, cordial, squashes, and lemonade, which collectively are the largest contributor to added sugar intake in the US. It has long been suspected that SSBs have an etiologic role in the obesity epidemic, however only recently have large epidemiological studies been able to quantify the relationship between SSB consumption and long-term weight gain, type 2 diabetes (T2DM) and cardiovascular disease (CVD) risk. Experimental studies have provided important insight into potential underlying biological mechanisms. It is thought that SSBs contribute to weight gain in part by incomplete compensation for energy at subsequent meals following intake of liquid calories. They may also increase risk of T2DM and CVD as a contributor to a high dietary glycemic load leading to inflammation, insulin resistance and impaired β-cell function. Additional metabolic effects from the fructose fraction of these beverages may also promote accumulation of visceral adiposity, and increased hepatic de novo lipogenesis, and hypertension due to hyperuricemia. Consumption of SSBs should therefore be replaced by healthy alternatives such as water, to reduce risk of obesity and chronic diseases.

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

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