Cited by 947Diet, Metabolism, and DiseaseNutritional Studies and DietObesity, Physical Activity, Diet

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Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

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Yang, Quanhe, Zhang, Zefeng, Gregg, Edward W., Flanders, W. Dana, Merritt, Robert, Hu, Frank B.·2014·JAMA Internal Medicine

DOI 10.1001/jamainternmed.2013.13563PMC PMC10910551

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Abstract

IMPORTANCE Epidemiologic studies have suggested that higher intake of added sugar is associated with cardiovascular disease (CVD) risk factors. Few prospective studies have examined the association of added sugar intake with CVD mortality. OBJECTIVE To examine time trends of added sugar consumption as percentage of daily calories in the United States and investigate the association of this consumption with CVD mortality. DESIGN, SETTING, AND PARTICIPANTS National Health and Nutrition Examination Survey (NHANES, 1988-1994 [III], 1999-2004, and 2005-2010 [n = 31,147]) for the time trend analysis and NHANES III Linked Mortality cohort (1988-2006 [n = 11 733]), a prospective cohort of a nationally representative sample of US adults for the association study. MAIN OUTCOMES AND MEASURES Cardiovascular disease mortality. RESULTS Among US adults, the adjusted mean percentage of daily calories from added sugar increased from 15.7% (95% CI, 15.0%-16.4%) in 1988-1994 to 16.8% (16.0%-17.7%; P = .02) in 1999-2004 and decreased to 14.9% (14.2%-15.5%; P < .001) in 2005-2010. Most adults consumed 10% or more of calories from added sugar (71.4%) and approximately 10% consumed 25% or more in 2005-2010. During a median follow-up period of 14.6 years, we documented 831 CVD deaths during 163,039 person-years. Age-, sex-, and race/ethnicity-adjusted hazard ratios (HRs) of CVD mortality across quintiles of the percentage of daily calories consumed from added sugar were 1.00 (reference), 1.09 (95% CI, 1.05-1.13), 1.23 (1.12-1.34), 1.49 (1.24-1.78), and 2.43 (1.63-3.62; P < .001), respectively. After additional adjustment for sociodemographic, behavioral, and clinical characteristics, HRs were 1.00 (reference), 1.07 (1.02-1.12), 1.18 (1.06-1.31), 1.38 (1.11-1.70), and 2.03 (1.26-3.27; P = .004), respectively. Adjusted HRs were 1.30 (95% CI, 1.09-1.55) and 2.75 (1.40-5.42; P = .004), respectively, comparing participants who consumed 10.0% to 24.9% or 25.0% or more calories from added sugar with those who consumed less than 10.0% of calories from added sugar. These findings were largely consistent across age group, sex, race/ethnicity (except among non-Hispanic blacks), educational attainment, physical activity, health eating index, and body mass index. CONCLUSIONS AND RELEVANCE Most US adults consume more added sugar than is recommended for a healthy diet. We observed a significant relationship between added sugar consumption and increased risk for CVD mortality.

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“For example, increases in sugar intake were seen at the population level during the time when low-fat diets were highly recommended (26).”
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Association of Consumption of Sugar-Sweetened Beverages or Artificially Sweetened Beverages with Mortality: A Systematic Review and Dose–Response Meta-Analysis of Prospective Cohort Studies
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“Four cohorts recruited females only (10, 17, 19, 33), 3 cohorts recruited males only (10, 33), and 10 cohorts (8, 9, 11, 13, 14, 15, 16, 18, 20, 21, 28) reported results in females and males together [among which, 1 study also conducted subgroup analysis according to sex (14)].”
Background
Effectiveness and equity of sugar-sweetened beverage taxation
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“For instance, from a public heath perspective, increased and overconsumption of high-sugar foods may lead to negative health outcomes while concurrently resulting in lower GHGE((69)).”
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“Is it just a function of “added sugar” in the diet (Johnson et al. 2009; Yang et al. 2014), or does fructose have unique characteristics associated with these pathologies? Persistently elevated high fructose, but not glucose intake, has been associated with development of hypertension, followed by type-2 diabetes and…”
Background
Current WHO recommendation to reduce free sugar intake from all sources to below 10% of daily energy intake for supporting overall health is not well supported by available evidence
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“Likewise, UPF provide added sugars (35) , which contributes to the excessive consumption of added sugars that has been associated with increased CVD mortality (54) .”
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“The physical health consequences of sugar overconsumption such as weight gain and cardiovascular disease are well documented [3].”
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“Furthermore, high consumption of added sugar (18 – 21) , sodium (22,23) , saturated fat (24) and trans -fat (25) has been associated in the past with the development of CVD (13,19,22) .”
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Vasopressin mediates fructose-induced metabolic syndrome by activating the V1b receptor
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Influential
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“INTRODUCTION Added-sugar (AS)(6) consumption is a key dietary intervention target because evidence has shown that excessive intake is a contributor to obesity (1, 2) and related comorbidities such as type 2 diabetes (3, 4) and cardiovascular disease (2).”
Background
Prospective association between added sugars and frailty in older adults
Laclaustra, M., Rodríguez‐Artalejo, F., Guallar‐Castillón, P., Banegas, J. R., Graciani, A., García‐Esquinas, E., Ordovás, J. M., & López‐García, E. (2018) · American Journal of Clinical Nutrition · doi:10.1093/ajcn/nqy028 · Cited by 58
“The unhealthy effects of sugar sweetening beyond beverages have also been studied, and such studies have shown that the amount of added sugars in the whole diet is associated with cardiovascular mortality in US adults (7).”
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Fast-Food Consumption, Dietary Quality, and Dietary Intake of Adolescents in Saudi Arabia
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Background
Silver nanoparticles-based plasmonic assay for the determination of sugar content in food matrices
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High consumption of ultra-processed food may double the risk of subclinical coronary atherosclerosis: the Aragon Workers’ Health Study (AWHS)
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Health Effects of Fructose and Fructose-Containing Caloric Sweeteners: Where Do We Stand 10 Years After the Initial Whistle Blowings?
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Adherence to a plant-based diet in relation to adipose tissue volumes and liver fat content
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Added Sugar, Sugar-Sweetened Beverages, and Artificially Sweetened Beverages and Risk of Cardiovascular Disease: Findings from the Women’s Health Initiative and a Network Meta-Analysis of Prospective Studies
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“reviewed 24 prospective cohort studies [3] and found only two that examined the role of added sugar in cardiovascular death [4,5], reporting a summary relative risk (95% confidence interval (CI)) of 1.”
BackgroundMethod
Estimating Free and Added Sugar Intakes in New Zealand
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Combined Consumption of Beef‐Based Cooked Mince and Sucrose Stimulates Oxidative Stress, Cardiac Hypertrophy, and Colonic Outgrowth of Desulfovibrionaceae in Rats
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Background
Are Fruit Juices Just as Unhealthy as Sugar-Sweetened Beverages?
Guasch‐Ferré, M., & Hu, F. B. (2019) · JAMA Network Open · doi:10.1001/jamanetworkopen.2019.3109 · Cited by 47

Authors: Yang, Q., Zhang, Z., Gregg, E. W., Flanders, W. D., Merritt, R., & Hu, F. B.
Affiliations: Centers for Disease Control and Prevention (US)
Emory University (US)
Harvard University (US)
Corresponding author: Yang, Quanhe
ORCID: Yang, Quanhe
Zhang, Zefeng
Gregg, Edward W.
Flanders, W. Dana
Merritt, Robert
Hu, Frank B.
Venue: JAMA Internal Medicine
Publisher: American Medical Association (AMA)
Published: 2014-04-01
Volume: 174
Issue: 4
Pages: 516
ISSN: 2168-6106 (ISSN-L)
DOI: 10.1001/jamainternmed.2013.13563
PMC: PMC10910551
OpenAlex: W2115321988
Cited by: 947
References: 49
Citations by year: 2026: 29 · 2025: 47 · 2024: 51 · 2023: 93 · 2022: 89 · 2021: 88 · 2020: 136 · 2019: 96 · 2018: 68 · 2017: 75 · 2016: 78 · 2015: 58 · 2014: 38
FWCI: 66.80
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Locations: JAMA Internal Medicine (publishedVersion)
PubMed (publishedVersion)
PubMed Central (acceptedVersion)
Funders: National Institutes of Health (CC999999)
Topics: Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diet, Metabolism, and Disease
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Nutritional Studies and Diet
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
Keywords: added sugar intake, cardiovascular mortality, sugar consumption, prospective cohort, cardiovascular risk factors, sociodemographic disparities, United States adults, sugar-sweetened beverages, fruit and vegetable intake, alcohol consumption, physical activity, smoking, body mass index, blood pressure
MeSH terms: Adult, Aged, Energy Intake, Carbohydrates, Cardiovascular Diseases, Female, Humans, Male, Middle Aged, Nutrition Surveys, Prospective Studies, Risk, United States

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Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

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