Substitution of sugar-sweetened beverages for other beverages and the risk of developing coronary heart disease: Results from the Harvard Pooling Project of Diet and Coronary Disease
Introduction
One-half of US adults consumes ≥1 sugar-sweetened beverage (SSB) daily, representing 6.5% of total energy intake (TEI) (Rosinger et al., 2011). Direct associations between SSB consumption and weight gain, obesity (Hu, 2013) and type-2 diabetes mellitus (T2DM) have been shown (Malik et al., 2010; Imamura et al., 2015); and each additional daily serving of SSBs has been associated with a 22% increased risk of myocardial infarction (MI) and 13% increased risk of stroke (Narain et al., 2016). A recent meta-analysis of published studies found that SSB consumption is positively associated with coronary heart disease (CHD), stroke and heart failure (Bechthold et al., 2017). Furthermore, high intake of SSBs has also been associated with increased blood pressure and hyperlipidemia (Keller et al., 2015; Xi et al., 2015). As one-third of deaths worldwide are attributable to cardiovascular disease (CVD), mainly CHD (WHO, 2017), evaluation of potential strategies for reducing the burden of CHD is needed.
Although individual studies have shown an inverse association between coffee, tea and possibly milk intakes (Soedamah-Muthu et al., 2011; Ding et al., 2014; Stangl et al., 2006) and the risk of CVD and limiting SSB consumption is recommended by public health agencies, there is insufficient evidence of what constitutes appropriate replacement beverages to make recommendations related to lowering the risk of developing CHD. Previous substitution studies have shown that substitution of water, milk, artificially-sweetened beverage (ASB), plain tea or coffee for SSBs was associated with a lower risk of weight gain, obesity and T2DM (Imamura et al., 2015; Zheng et al., 2015; Fresán et al., 2016; Pan et al., 2013; de Koning et al., 2011). In regards to cardiovascular health, results from intervention studies evaluating the effect of replacing SSBs by other beverages on CVDs showed discrepant results (Tate et al., 2012; Hernández-Cordero et al., 2017; Hernandez-Cordero et al., 2014); while results from observational studies suggested that substituting SSBs with fruit juice and water or coffee was associated with a lower risk of metabolic syndrome (Mattei et al., 2012) and stroke (Bernstein et al., 2012), respectively. Therefore, we aimed to supplement the growing evidence regarding the association between SSB intake and the risk of incident CHD using standardized modeling of the exposure and confounding variables to remove potential sources of noncomparability and heterogeneity that occur in the published literature, and to assess whether substitution of coffee, tea, milk, fruit juice and ASB for SSBs was associated with a lower risk of CHD events and deaths.
Section snippets
Subjects and methods
Six of the eleven studies from the Harvard Pooling Project (HPP) of Diet and Coronary Disease were included. The HPP inclusion criteria were prospective studies with ≥150 incident coronary cases, assessment of usual dietary intake, and a validation of the diet assessment method (Jakobsen et al., 2009). Only participants aged ≥35 years, without a history of CVD, diabetes, or cancer or extreme energy intake (ie, > or < 3 SDs from the study-specific log-transformed mean energy intake of the
Results
Characteristics of participants from included studies are presented in Table 1 and daily dietary intakes at baseline are presented in Tables S1a and S1b.. During the median 8.2-year follow-up, 4248 CHD events and 1630 CHD deaths occurred among 284,345 individuals (Supplementary data: Fig. S1). The daily median intake of SSBs was 48 ml with 37% reporting no drinking of SSBs in the previous year. In the following, all results refer to Model 3.
Combined HRs for 355 ml (12 oz) daily increase of SSB
Discussion
This study suggests that daily increase of SSB intake is associated with an increased risk of coronary events. These results are in accordance with recent evidence suggesting a direct association between SSB intake and CHD (Bechthold et al., 2017; Xi et al., 2015). In addition, this study reports several novel findings. Substitution analyses suggested that replacing SSBs with ASBs or coffee lowers the risk of developing CHD events. Although not statistically significant, substituting tea, total
Conclusion
This study shows that SSB intake is associated with an increased risk of coronary events and possibly coronary death among Western middle-aged populations. Our findings also suggest that replacing SSBs with ASBs or coffee may lower the risk of developing CHD events.
Declaration of competing interest
None of the authors had any conflicts of interest.
Acknowledgments
We would like to thank Dr. Ascherio for his contribution in obtaining the data. The Authors thank the ARIC, NHS, HPFS, WHS, IWHS and ATBC study participants. The Atherosclerosis Risk in Communities study has been funded in whole or in part with Federal funds from the National Heart, Lung, and Blood Institute, National Institutes of Health, Department of Health and Human Services (contract numbers HHSN268201700001I, HHSN268201700002I, HHSN268201700003I, HHSN268201700004I and HHSN268201700005I).
Funding
This project was supported by the Hjerteforeningen (14-R97-A5012), Region Hovedstaden, Etly og Jørgen Stjerngrens Fond, the Swiss Foundation for Nutrition Research (480), Oticon fonden (15-0487), Niehls Bohr fondet (SKMBT_C45215111114270). The funders had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.
Authors contribution
Berit L. Heitmann, Ingelise Andersen and Amélie Keller designed the study and formulated the research question. Eilis O'Reilly and Amélie Keller performed the statistical analyses. Vasanti Malik and Eilis O'Reilly provided feedback on the study design. Amélie Keller wrote the manuscript. Eric Rimm and Walter Willett provided interpretation of data and critical revision of the manuscript for important intellectual content.
The remaining investigators (Julie E. Buring, Lyn Steffen, Kim Robien and
Transparency declaration
The lead author, Amélie Cléo Keller, affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as originally planned (and, if relevant, registered) have been explained.
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