Published: Feb 3, 2014 | Updated: Feb 4, 2014
By Todd Neale, Senior Staff Writer, MedPage Today

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Through a median follow-up of nearly 15 years, those who had 10% to 24.9% of calories come from added sugar were 30% more likely to experience cardiovascular death than those with less than 10% (HR 1.30, 95% CI 1.09-1.55), according to Quanhe Yang, PhD, of the CDC’s Division for Heart Disease and Stroke Prevention in Atlanta, and colleagues.

In addition, the risk of death during the follow-up period jumped greatly — to 175% — for those getting 25% or more of their calories from added sugar (HR 2.75, 95% CI 1.40-5.42), they reported online in JAMA Internal Medicine. The findings were mostly consistent across subgroups, although the relationships were not significant in non-Hispanic blacks.

The study “underscores the likelihood that, at levels of consumption common among Americans, added sugar is a significant risk factor for cardiovascular disease mortality above and beyond its role as empty calories leading to weight gain and obesity,” Laura Schmidt, PhD, MPH, of the University of California San Francisco, wrote in an accompanying editorial.

“Yang et al. underscore the need for federal guidelines that help consumers set safe limits on their intake as well as evidence-based regulatory strategies that discourage excess sugar consumption at the population level.”

Added sugar is ubiquitous in processed or prepared foods, such as sodas and other sugar-sweetened beverages, desserts, fruit drinks, and candy. A typical can of regular soda contains about 35 grams of sugar, which equates to 7% of total calories in a 2,000 calorie/day diet.

Observational studies have established a link between eating more added sugar (mostly in the form of sugar-sweetened beverages) and poorer cardiovascular health, including increased weight gain and greater risks of obesity, type 2 diabetes, dyslipidemia, hypertension, andcardiovascular disease.

Supported by that literature, various organizations have released recommendations for added sugar consumption. The Institute of Medicine says that less than 25% of calories should come from added sugar, but the World Health Organization recommends a more cautious 10% threshold. The American Heart Association’s recommendation that added sugar should make up less than 100 calories a day for women and 150 calories per day for men is more in line with the WHO’s guidance.

Few studies have examined the relationship between added sugar consumption and cardiovascular death; however, and Yang and colleagues explored the issue using data from the National Health and Nutrition Examination Survey. The analysis included 31,147 people who participated in the survey from 1988 to 2010 for a time trend analysis and 11,733 who were included in the wave from 1988 to 1994 and were followed through 2006 for the mortality analysis.

The participants all completed 24-hour dietary recalls that were used to determine intake of added sugar, which did not include sugar from fruit or fruit juices.

Over the study period, the average percentage of daily calories that came from added sugar increased from 15.7% in 1988-1994 to 16.8% in 1999-2004, but then declined to 14.9% in 2005-2010.

Nonetheless, in the latest time period, most adults in the study (71.4%) consumed at least 10% of their calories in the form of added sugar, and one out of every 10 had 25% of their calories come from added sugar.

Even after adjustment for sociodemographics, overall diet quality, and various cardiovascular risk factors, the risk of cardiovascular mortality through follow-up was significantly elevated across quintiles of greater added sugar consumption.

For sugar-sweetened beverages specifically, people who consumed at least seven servings per week had a greater risk of dying from cardiovascular disease compared with those who consumed no more than one (HR 1.29, 95% CI 1.04-1.60).

“The results reported by Yang and colleagues support the logic for singling out sugar-sweetened beverages for taxation,” Schmidt wrote. “Sugar-sweetened beverages are by far the single largest source of added sugar in the American diet, accounting for 37.1% of all that is consumed nationally.”

She noted that the risk of cardiovascular mortality started to increase when intake of added sugar reached 15% of daily calories, which is “equivalent to drinking one 20-ounce Mountain Dew soda in a 2,000-calorie daily diet.”

“These findings provide physicians and consumers with actionable guidance,” she wrote. “Until federal guidelines are forthcoming, physicians may want to caution patients that, to support cardiovascular health, it is safest to consume less than 15% of their daily calories as added sugar.”

The authors acknowledged some limitations of their study, including the inability to account for changes in added sugar intake over time in the association analysis, the possibility of residual confounding, and the inability to establish causality in the observed relationships.

From the American Heart Association:

• Dietary Sugars Intake and Cardiovascular (CV) Health
• Non-Nutritive Sweeteners: Current Use and Health Perspectives

Primary source: JAMA Internal Medicine

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