H E R BA L S A N D N U T R I T I O N A L S U P P L E M E N T S
Cardiovascular Disease Mortality The Deleterious Effects of Excess Dietary Sugar Intake ■
Stephanie Maxine Ross, MH, MS, HT, CNC, PDMT Holist Nurs Pract 2015;29(1):53–57
Randomized clinical trials and epidemiologic clarification. Sugars in general are ubiquitous studies have shown that individuals with a high intake substances that are integral components found in our of extrinsic (added) dietary sugar, derived particularly food source. Intrinsic or naturally occurring sugar from sugar-sweetened beverages, tend to gain refers to sugar that is an inherent constituent of whole more weight1 and have a higher risk fruit, vegetables, and milk products; of obesity,2-6 type 2 diabetes mellitus,3 extrinsic or added sugar refers to An excess 7,8 9,10 dyslipidemia, hypertension, and sucrose (table sugar) or other refined of added an increased risk of cardiovascular sugars, such as fructose corn syrup that sugar disease (CVD).11,12 are found in soft drinks and incorporated increases Recent studies provide evidence that a in processed food, fruit drinks, energy the risk for significant relationship exists between drinks, and other beverages. CVD added sugar intake and the increased risk Dietary carbohydrates (sugars) mortality.13 for CVD mortality.13 Because of the everas they occur in nature are central to increasing body of rigorous studies in this human nutrition and provide the primary area, the emerging scientific perspective views source of energy needed to fuel physiological excessive added sugar intake as an independent risk functions. They are classified into 2 basic groups: factor for CVD, as well as for other chronic diseases simple and complex carbohydrates. such as diabetes, liver cirrhosis, and dementia—all r Simple carbohydrates are either monosaccharides connected to metabolic disturbances that involve (composed of 1 sugar molecule) or disaccharides dyslipidemia, hypertension, and insulin resistance.14,15 (composed of 2 sugar molecules). The principle monosaccharides that occur in foods are glucose SUGAR CLASSIFICATION and fructose. Fructose, or fruit sugar, is the primary Differentiating terminology naturally occurring carbohydrate found in fruits and vegetables. The major disaccharide is sucrose, also There are various terminologies used in the literature known as white sugar, which is composed of 1 to describe sugars that are often confusing and merit molecule of glucose and 1 molecule of fructose. Sucrose, which is common table sugar, is found in Author Affiliation: College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania. a large number of processed foods and sweetened beverages. The author has disclosed that she has no significant relationships with, or r Complex carbohydrates, refers to glucosefinancial interest in, any commercial companies pertaining to this article. Correspondence: Stephanie Maxine Ross, MH, MS, HT, CNC, PDMT, Ascontaining polysaccharides, such as starch. The sociate Science Editor, Director, and Clinical Assistant Professor, Advanced more complex a carbohydrate, the more slowly it Study in Complementary and Integrative Health Programs, College of Nursis broken down into simple sugars, which leads to ing and Health Professions, Drexel University, 1505 Race St, Philadelphia, PA19102 ([email protected]). better sugar control. Research continues to confirm DOI: 10.1097/HNP.0000000000000066 that a whole-foods–based diet, rich in vegetables, 53 Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
54
HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2015
whole grains, legumes, seeds, and nuts—all complex carbohydrates high in fiber, should form the foundation for a healthy dietary plan.
INCIDENCE OF SUGAR CONSUMPTION There is a worldwide prevalence of diabetes, obesity, and CVD that is concomitant with the high intake of excessive dietary sugars. According to the United States Department of Agriculture’s Economic Research Service, between 1970 and 2005, sugars and sweeteners available for consumption increased by an average of 76 cal/d, from 25 teaspoons (400 cal) to 29.8 teaspoons (476 cal), equivalent to a 19% increase in Americans’ average daily calorie intake.16 Based on the data from the 2001 to 2004 National Health and Nutrition Examination Survey (NHANES), the average mean intake of added sugars for all Americans was 22.2 teaspoons per day (355 cal/d); children between the ages of 14 and 18 years had the highest intake of added sugar at 34.3 teaspoons per day (549 cal).17 Soft drinks and other sweetened beverages have been identified as the primary source of added sugars in American’s diets.18 Between 1970 and 2000, the daily consumption of caloric soft drinks on a per person basis increased 70%, from 7.8 oz to 13.2 oz.19
disturbances that stimulate increases in appetite, weight gain, diabetes, and CVD. Human studies link soft drink consumption with higher caloric intake, increased body weight, and poor nutrition.24,25 Furthermore, the studies suggest that excess consumption of fructose (HFCS) plays a principle role in the widespread incidence of insulin resistance, obesity, type 2 diabetes, hypertension, and dyslipidemia.26-29
CARDIOVASCULAR DISEASE MORTALITY Effects of excess added dietary sugar Extensive, well-designed studies have demonstrated that individuals who consume a high intake of added dietary sugar, especially from sugar-sweetened beverages, have a propensity to gain more weight and have a higher risk of obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, and an increased risk of CVD.1-12 Recent studies have shown evidence that a significant relationship exists between added sugar intake and the increased risk for CVD mortality.13
Research in review
HIGH-FRUCTOSE CORN SYRUP High-fructose corn syrup (HFCS) is not to be confused with fructose or fruit sugar that is naturally inherent in fruits and vegetables. High-fructose corn syrup is a biochemical compound, manufactured by the food industry. It is composed of 55% fructose, which is extracted chemically from corn stalks and 45% glucose and is similar in composition to table sugar (sucrose), but it is sweeter and much less expensive.20,21 High-fructose corn syrup is the sweetener that is predominately used by the beverage industry. Research points to HFCS as a contributor to the emergence of metabolic syndrome. Fructose due to its chemical composition is metabolized differently than glucose, where it is directed to the liver and undergoes lipogenesis, which over time results in accumulated liver fat and may ultimately lead to nonalcoholic fatty liver disease, which presently affects more than 70 million Americans.22,23 The glucose component of HFCS is rapidly absorbed into the bloodstream and stimulates spikes in insulin. These physiological responses taken together lead to increased metabolic
Yang Q, Zhang Z, Gregg E, Flanders D, Merritt R, Hu FB. Added sugar intake and cardiovascular disease mortality among US adults. JAMA Intern Med. 2014;174(4):516-524.
Objective The purpose of this study was to analyze time trends of added sugar intake as a percentage of total daily calories using a series of national representative samples. In addition, the study investigated the association of this consumption with CVD mortality using a prospective cohort of a nationally representative sample of adults in the United States.
Study design overview This study included 2 analyses: a trends analysis of added dietary sugar intake and an association study of this consumption with CVD mortality. The trend analysis served to estimate added sugar consumption over time in the US population. It utilized data collected from a series of cross-sectional surveys known as the NHANES, spanning a continuum period
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
55
Cardiovascular Disease Mortality
from 1988 through 2010 (n = 31147). To investigate the relationship between sugar consumption and death from CVD, an association analysis was applied using data from a prospective cohort known as NHANES III Linked Mortality Cohort (1988-2006 [n = 11733]), which linked with a probabilistic matching algorithm to the national index to determine mortality status. The methodology criteria and detailed description is detailed in the National Center for Health Statistics, Office of Analysis & Epidemiology.30,31
Summary of results Study results indicated that among US adults, the mean percentage of daily calories (based on 2000 kcal/d) derived from added sugar increased from 15.7% in 1988-1994 to 16.8% in 1999-2004 and decreased to 14.9% in 2005-2010. In general, the majority of adults consumed 10% or more of their total calories from added sugar (71.4%) and approximately 10% consumed 25% or more of calories from added sugar in 2015-2010. In comparison with test subjects who consumed approximately 8% of calories from added sugar, participants who consumed approximately 17% to 21% of calories from added sugar incurred a 38% increased risk of CVD risk mortality. The risk of CVD mortality increased exponentially, with an increased percentage in the consumption of added sugar. In fact,
the relative increased risk for CVD mortality was more than double for individuals who consumed 21% or more of calories from added sugar; for those who consumed 25% or more of calories from added sugar, the relative increased risk was almost tripled.
Discussion of results The highest sources of added sugar, which includes all sugars added to processed or prepared foods in American adults’ diet, are sugar-sweetened beverages (37.1%), grain-based desserts (13.7%), and fruit drinks (8.9%).32 The Table lists the sources of added sugars in the diets of the US population, NHANES 2005-2006. As an illustrative example, a typical 12 Fl oz (355 mL) can of soda contains 41 g of sugar (4 g of sugar = 1 teaspoon of sugar; therefore, 41 g = 10.25 teaspoons of sugar) in the form of HFCS (150 cal) or 14% of total calories (based on 2000 kcal/d); one 16 Fl oz (473 mL) can of high energy drink contains approximately 54 g of sugar (equivalent to 13.5 teaspoons of sugar; 210 cal) or 19% of total calories. There is presently no general consensus or universal guideline for recommended added sugar consumption, and recommendations from notable sources vary considerably. The World Health Organization recommends less than 10% of calories from added sugar on the basis of its review of adverse health outcomes.33 The American Heart Association,
TABLE. Mean Intake of Added Sugars and Percentage Contribution of Various Foods Among US Population, by Age, NHANES 2005-2006a
Sample size Mean intake of added sugars (tsp) Rankb 1 2 3 4 5 6 7 8 9 10
Food groupc,d Soda/energy/sports drinks Grain-based desserts Fruit drinks Dairy desserts Candy Ready-to-eat cereals Sugars/honey Tea Yeast breads Syrups/toppings
All Persons
2-18 y
19+ y
8272 21
3553 23
4719 20
35.7
31.8
37.1
12.9 10.5 6.6 6.1 3.8 3.5 3.5 2.1 1.9
10.9 15.0 7.9 6.8 6.4 1.4 2.1 1.9 2.8
13.7 8.9 6.1 5.8 2.9 4.2 4.0 2.2 1.5
a
From National Cancer Institute.32 Rank for all persons only. Columns for other age groups are ordered by this ranking. The top 5 food groups for each age group are bolded. c Specific foods contributing at least 2% of added sugar for all persons in descending order are listed. Specific foods contributing at least 2% of added sugar for any given subgroup are then also listed in italics. d Specific foods contributing at least 1% of added sugar for all persons in descending order: syrups/toppings. b
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
56
HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2015
based on evidence of increased added sugar consumption and its association with CVD, recommends that total calories derived from added sugar should be less than 100 cal/d for the majority of women and less than 150 cal/d for most men.34
SUMMARY OF RESULTS Randomized clinical trials and epidemiologic studies have shown that individuals who consume a high intake of added dietary sugar, derived from sugar-sweetened processed foods and beverages, have an increased risk of CVD. Further evidence indicates that added dietary sugar is associated with a significant increased risk of CVD mortality. These research outcomes provide compelling evidence of the deleterious effects of excess added sugar on cardiovascular health parameters and are supportive of current recommendations to limit the intake of added sugar consumption on a daily basis in the standard American diet (SAD).
REFERENCES 1. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight; systematic review and meta-analyses of randomized controlled trials and cohort studies. BMJ. 2013;346:e7492. 2. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med. 2012;367(15):1407-1416. 3. Hu FB, Malik VS. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav. 2010;100(1):47-54. 4. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274288. 5. Malik VS, Willett WC, Hu FB. Sugar-sweetened beverages and BMI in children and adolescents: reanalyses of meta-analysis. Am J Clin Nutr. 2009;89(1):438-440. 6. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk obesity. N Engl J Med. 2012;367(15):1387-1396. 7. Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults. JAMA. 2010;303(15):1490-1497. 8. Welsh JA, Sharma A, Cunningham SA, Vos MB. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation. 2011;123(3):249-257. 9. Brown IJ, Stamier J, Van Horn L, et al. International Study of Macro/Micronutrients and Blood Pressure Research Group. Sugarsweetened beverage, sugar intake of individuals, and their blood pressure: international macro/micronutrients and blood pressure. Hypertension. 2011;57(4):695-701. 10. Chen L, Caballero B, Mitchell DC, et al. Reducing consumption of sugar- sweetened beverages is associated with reduced blood pressure a prospective study among United States adults. Circulation. 2010;121(22):2398-2406. 11. Malik VS, Popkin BM, Bray GA, Despres JP, HU FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121(11):1356-1364.
12. De Koning L, Malik VS, Kellogg MD, Rimm EB, Willet WC, HU FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation. 2012;125(14):17351741. 13. Yang Q, Zhang Z, Gregg E, Flanders D, Merritt R, Hu FB. Added sugar intake and cardiovascular disease mortality among US adults. JAMA Intern Med. 2014;174(4):516-524. 14. Lustig RH, Schmidt LA, Brindis CD. The toxic truth about sugar. Nature. 2012;483(7383):27-29. 15. Basu S, Yoffe P, Hills N, Lustig RH. The relationship of sugar to population level diabetes prevalence: an econometric analysis of repeated cross-sectional data. PLoS One. 2013;8(2):e57873. 16. Wells HF, Buzby JC. Dietary Assessment of Major Trends in US Food Consumption, 1970-2005. Washington, DC: Economic Research Service, US Department of Agriculture; 2008. Economic Information Bulletin No. 33. 17. National Cancer Institute. Usual intake of added sugars. Usual Dietary Intakes: Food Intakes, US Population 2001–04. http://riskfactor.cancer .gov/diet/usualintakes/pot35.html. Published 2008. Accessed October 5, 2014. 18. Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc. 2000;100:43-51. 19. Frazao E, Allshouse J. Strategies for intervention: commentary and debate. J Nutr. 2003;133:844S-847S. 20. Takasaki Y. Studies on sugar isomerizing enzyme: production and utilization of glucose isomerase from Streptomyces spp. Agric Biol Chem. 1966;30:1247-1253. 21. Coulston AM, Johnson RK. Sugar and sugars: myths and realities. J Am Diet Assoc. 2002;102:351-353. 22. Ackerman Z, Oron-Herman M, Grozovski M, et al. Fructose-induced fatty liver disease: hepatic effects of blood pressure and plasma triglyceride reduction. Hypertension. 2005;45:1012-1018. 23. Ouyang X, Cirillo P, Sautin Y, et al. Fructose consumption as a risk factor for non-alcoholic fatty liver disease. J Hepatol. 2008;48(6):993999. 24. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: a systematic review and meta-analysis. Am J Public Health. 2007;97:667-675. 25. Tordoff MG, Alleva AM. Effect of drinking soda sweetened with aspartame or high-fructose corn syrup on food intake and body weight. Am J Clin Nutr. 1990;51:963-969. 26. Lˆe KA, Tappy L. Metabolic effects of fructose. Curr Opin Clin Nutr Metab Care. 2006;9:469-475. 27. Havel PJ. Dietary fructose: implications for dysregulation of energy homeostasis and lipid/carbohydrate metabolism. Nutr Rev. 2005; 63:133-157. 28. Gross LS, Li S, Ford ES, Liu S. Increased consumption of refined carbohydrates and the epidemic of type 2 diabetes in the United States: an ecologic assessment. Am J Clin Nutr. 2004;79:774-779. 29. Elliott SS, Keim NL, Stern JS, Teff K, Havel PJ. Fructose, weight gain, and the insulin resistance syndrome. Am J Clin Nutr. 2002;76: 911-922. 30. National Center for Health Statistics Office of Analysis and Epidemiology. National Health and Nutrition Examination Survey (NHANES) 1999-2004 linked mortality files, mortality follow-up through 2006: matching methodology. http://www.cdc.gov/nchs/data/datalinkage/ nh99+ mortality matching methodology final.pdf. Accessed October 5, 2014. 31. National Center for Health Statistics, Office of Analysis and Epidemiology. The Third National Health and Nutrition Examination Survey (NHANES III) linked mortality files, mortality followup through 2006: matching methodology. http://www.cdc.gov/nchs/ data/datalinkage/matching methodology nhanes3 final.pdf. Accessed October 5, 2014. 32. National Cancer Institute. Sources of calories from added sugars among the US population, 2005–06. Applied Research Program Web
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cardiovascular Disease Mortality site. http://appliedresearch.cancer.gov/diet/foodsources/added sugars/ table5a.html. Updated April 11, 2014. Accessed October 12, 2014. 33. Nishida C, Uauy R, Kumanyika S, Shetty P. The joint WHO/FAO expert consultation on diet, nutrition and the prevention of chronic diseases: process, product and policy implications. Public Health Nutr. 2004;7(1A):245-250.
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34. Johnson RK, Appel LJ, Brands M, et al.; on behalf of the American Heart Association Nutrition Committee of the Council on Nutrition, Physical Activity, and Metabolism and the Council on Epidemiology and Prevention. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation. 2009;120:1011-1020.
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Cardiovascular Disease Mortality The Deleterious Effects of Excess Dietary Sugar Intake ■
Stephanie Maxine Ross, MH, MS, HT, CNC, PDMT Holist Nurs Pract 2015;29(1):53–57
Randomized clinical trials and epidemiologic clarification. Sugars in general are ubiquitous studies have shown that individuals with a high intake substances that are integral components found in our of extrinsic (added) dietary sugar, derived particularly food source. Intrinsic or naturally occurring sugar from sugar-sweetened beverages, tend to gain refers to sugar that is an inherent constituent of whole more weight1 and have a higher risk fruit, vegetables, and milk products; of obesity,2-6 type 2 diabetes mellitus,3 extrinsic or added sugar refers to An excess 7,8 9,10 dyslipidemia, hypertension, and sucrose (table sugar) or other refined of added an increased risk of cardiovascular sugars, such as fructose corn syrup that sugar disease (CVD).11,12 are found in soft drinks and incorporated increases Recent studies provide evidence that a in processed food, fruit drinks, energy the risk for significant relationship exists between drinks, and other beverages. CVD added sugar intake and the increased risk Dietary carbohydrates (sugars) mortality.13 for CVD mortality.13 Because of the everas they occur in nature are central to increasing body of rigorous studies in this human nutrition and provide the primary area, the emerging scientific perspective views source of energy needed to fuel physiological excessive added sugar intake as an independent risk functions. They are classified into 2 basic groups: factor for CVD, as well as for other chronic diseases simple and complex carbohydrates. such as diabetes, liver cirrhosis, and dementia—all r Simple carbohydrates are either monosaccharides connected to metabolic disturbances that involve (composed of 1 sugar molecule) or disaccharides dyslipidemia, hypertension, and insulin resistance.14,15 (composed of 2 sugar molecules). The principle monosaccharides that occur in foods are glucose SUGAR CLASSIFICATION and fructose. Fructose, or fruit sugar, is the primary Differentiating terminology naturally occurring carbohydrate found in fruits and vegetables. The major disaccharide is sucrose, also There are various terminologies used in the literature known as white sugar, which is composed of 1 to describe sugars that are often confusing and merit molecule of glucose and 1 molecule of fructose. Sucrose, which is common table sugar, is found in Author Affiliation: College of Nursing and Health Professions, Drexel University, Philadelphia, Pennsylvania. a large number of processed foods and sweetened beverages. The author has disclosed that she has no significant relationships with, or r Complex carbohydrates, refers to glucosefinancial interest in, any commercial companies pertaining to this article. Correspondence: Stephanie Maxine Ross, MH, MS, HT, CNC, PDMT, Ascontaining polysaccharides, such as starch. The sociate Science Editor, Director, and Clinical Assistant Professor, Advanced more complex a carbohydrate, the more slowly it Study in Complementary and Integrative Health Programs, College of Nursis broken down into simple sugars, which leads to ing and Health Professions, Drexel University, 1505 Race St, Philadelphia, PA19102 ([email protected]). better sugar control. Research continues to confirm DOI: 10.1097/HNP.0000000000000066 that a whole-foods–based diet, rich in vegetables, 53 Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
54
HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2015
whole grains, legumes, seeds, and nuts—all complex carbohydrates high in fiber, should form the foundation for a healthy dietary plan.
INCIDENCE OF SUGAR CONSUMPTION There is a worldwide prevalence of diabetes, obesity, and CVD that is concomitant with the high intake of excessive dietary sugars. According to the United States Department of Agriculture’s Economic Research Service, between 1970 and 2005, sugars and sweeteners available for consumption increased by an average of 76 cal/d, from 25 teaspoons (400 cal) to 29.8 teaspoons (476 cal), equivalent to a 19% increase in Americans’ average daily calorie intake.16 Based on the data from the 2001 to 2004 National Health and Nutrition Examination Survey (NHANES), the average mean intake of added sugars for all Americans was 22.2 teaspoons per day (355 cal/d); children between the ages of 14 and 18 years had the highest intake of added sugar at 34.3 teaspoons per day (549 cal).17 Soft drinks and other sweetened beverages have been identified as the primary source of added sugars in American’s diets.18 Between 1970 and 2000, the daily consumption of caloric soft drinks on a per person basis increased 70%, from 7.8 oz to 13.2 oz.19
disturbances that stimulate increases in appetite, weight gain, diabetes, and CVD. Human studies link soft drink consumption with higher caloric intake, increased body weight, and poor nutrition.24,25 Furthermore, the studies suggest that excess consumption of fructose (HFCS) plays a principle role in the widespread incidence of insulin resistance, obesity, type 2 diabetes, hypertension, and dyslipidemia.26-29
CARDIOVASCULAR DISEASE MORTALITY Effects of excess added dietary sugar Extensive, well-designed studies have demonstrated that individuals who consume a high intake of added dietary sugar, especially from sugar-sweetened beverages, have a propensity to gain more weight and have a higher risk of obesity, type 2 diabetes mellitus, dyslipidemia, hypertension, and an increased risk of CVD.1-12 Recent studies have shown evidence that a significant relationship exists between added sugar intake and the increased risk for CVD mortality.13
Research in review
HIGH-FRUCTOSE CORN SYRUP High-fructose corn syrup (HFCS) is not to be confused with fructose or fruit sugar that is naturally inherent in fruits and vegetables. High-fructose corn syrup is a biochemical compound, manufactured by the food industry. It is composed of 55% fructose, which is extracted chemically from corn stalks and 45% glucose and is similar in composition to table sugar (sucrose), but it is sweeter and much less expensive.20,21 High-fructose corn syrup is the sweetener that is predominately used by the beverage industry. Research points to HFCS as a contributor to the emergence of metabolic syndrome. Fructose due to its chemical composition is metabolized differently than glucose, where it is directed to the liver and undergoes lipogenesis, which over time results in accumulated liver fat and may ultimately lead to nonalcoholic fatty liver disease, which presently affects more than 70 million Americans.22,23 The glucose component of HFCS is rapidly absorbed into the bloodstream and stimulates spikes in insulin. These physiological responses taken together lead to increased metabolic
Yang Q, Zhang Z, Gregg E, Flanders D, Merritt R, Hu FB. Added sugar intake and cardiovascular disease mortality among US adults. JAMA Intern Med. 2014;174(4):516-524.
Objective The purpose of this study was to analyze time trends of added sugar intake as a percentage of total daily calories using a series of national representative samples. In addition, the study investigated the association of this consumption with CVD mortality using a prospective cohort of a nationally representative sample of adults in the United States.
Study design overview This study included 2 analyses: a trends analysis of added dietary sugar intake and an association study of this consumption with CVD mortality. The trend analysis served to estimate added sugar consumption over time in the US population. It utilized data collected from a series of cross-sectional surveys known as the NHANES, spanning a continuum period
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
55
Cardiovascular Disease Mortality
from 1988 through 2010 (n = 31147). To investigate the relationship between sugar consumption and death from CVD, an association analysis was applied using data from a prospective cohort known as NHANES III Linked Mortality Cohort (1988-2006 [n = 11733]), which linked with a probabilistic matching algorithm to the national index to determine mortality status. The methodology criteria and detailed description is detailed in the National Center for Health Statistics, Office of Analysis & Epidemiology.30,31
Summary of results Study results indicated that among US adults, the mean percentage of daily calories (based on 2000 kcal/d) derived from added sugar increased from 15.7% in 1988-1994 to 16.8% in 1999-2004 and decreased to 14.9% in 2005-2010. In general, the majority of adults consumed 10% or more of their total calories from added sugar (71.4%) and approximately 10% consumed 25% or more of calories from added sugar in 2015-2010. In comparison with test subjects who consumed approximately 8% of calories from added sugar, participants who consumed approximately 17% to 21% of calories from added sugar incurred a 38% increased risk of CVD risk mortality. The risk of CVD mortality increased exponentially, with an increased percentage in the consumption of added sugar. In fact,
the relative increased risk for CVD mortality was more than double for individuals who consumed 21% or more of calories from added sugar; for those who consumed 25% or more of calories from added sugar, the relative increased risk was almost tripled.
Discussion of results The highest sources of added sugar, which includes all sugars added to processed or prepared foods in American adults’ diet, are sugar-sweetened beverages (37.1%), grain-based desserts (13.7%), and fruit drinks (8.9%).32 The Table lists the sources of added sugars in the diets of the US population, NHANES 2005-2006. As an illustrative example, a typical 12 Fl oz (355 mL) can of soda contains 41 g of sugar (4 g of sugar = 1 teaspoon of sugar; therefore, 41 g = 10.25 teaspoons of sugar) in the form of HFCS (150 cal) or 14% of total calories (based on 2000 kcal/d); one 16 Fl oz (473 mL) can of high energy drink contains approximately 54 g of sugar (equivalent to 13.5 teaspoons of sugar; 210 cal) or 19% of total calories. There is presently no general consensus or universal guideline for recommended added sugar consumption, and recommendations from notable sources vary considerably. The World Health Organization recommends less than 10% of calories from added sugar on the basis of its review of adverse health outcomes.33 The American Heart Association,
TABLE. Mean Intake of Added Sugars and Percentage Contribution of Various Foods Among US Population, by Age, NHANES 2005-2006a
Sample size Mean intake of added sugars (tsp) Rankb 1 2 3 4 5 6 7 8 9 10
Food groupc,d Soda/energy/sports drinks Grain-based desserts Fruit drinks Dairy desserts Candy Ready-to-eat cereals Sugars/honey Tea Yeast breads Syrups/toppings
All Persons
2-18 y
19+ y
8272 21
3553 23
4719 20
35.7
31.8
37.1
12.9 10.5 6.6 6.1 3.8 3.5 3.5 2.1 1.9
10.9 15.0 7.9 6.8 6.4 1.4 2.1 1.9 2.8
13.7 8.9 6.1 5.8 2.9 4.2 4.0 2.2 1.5
a
From National Cancer Institute.32 Rank for all persons only. Columns for other age groups are ordered by this ranking. The top 5 food groups for each age group are bolded. c Specific foods contributing at least 2% of added sugar for all persons in descending order are listed. Specific foods contributing at least 2% of added sugar for any given subgroup are then also listed in italics. d Specific foods contributing at least 1% of added sugar for all persons in descending order: syrups/toppings. b
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
56
HOLISTIC NURSING PRACTICE • JANUARY/FEBRUARY 2015
based on evidence of increased added sugar consumption and its association with CVD, recommends that total calories derived from added sugar should be less than 100 cal/d for the majority of women and less than 150 cal/d for most men.34
SUMMARY OF RESULTS Randomized clinical trials and epidemiologic studies have shown that individuals who consume a high intake of added dietary sugar, derived from sugar-sweetened processed foods and beverages, have an increased risk of CVD. Further evidence indicates that added dietary sugar is associated with a significant increased risk of CVD mortality. These research outcomes provide compelling evidence of the deleterious effects of excess added sugar on cardiovascular health parameters and are supportive of current recommendations to limit the intake of added sugar consumption on a daily basis in the standard American diet (SAD).
REFERENCES 1. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight; systematic review and meta-analyses of randomized controlled trials and cohort studies. BMJ. 2013;346:e7492. 2. Ebbeling CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med. 2012;367(15):1407-1416. 3. Hu FB, Malik VS. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav. 2010;100(1):47-54. 4. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2):274288. 5. Malik VS, Willett WC, Hu FB. Sugar-sweetened beverages and BMI in children and adolescents: reanalyses of meta-analysis. Am J Clin Nutr. 2009;89(1):438-440. 6. Qi Q, Chu AY, Kang JH, et al. Sugar-sweetened beverages and genetic risk obesity. N Engl J Med. 2012;367(15):1387-1396. 7. Welsh JA, Sharma A, Abramson JL, Vaccarino V, Gillespie C, Vos MB. Caloric sweetener consumption and dyslipidemia among US adults. JAMA. 2010;303(15):1490-1497. 8. Welsh JA, Sharma A, Cunningham SA, Vos MB. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation. 2011;123(3):249-257. 9. Brown IJ, Stamier J, Van Horn L, et al. International Study of Macro/Micronutrients and Blood Pressure Research Group. Sugarsweetened beverage, sugar intake of individuals, and their blood pressure: international macro/micronutrients and blood pressure. Hypertension. 2011;57(4):695-701. 10. Chen L, Caballero B, Mitchell DC, et al. Reducing consumption of sugar- sweetened beverages is associated with reduced blood pressure a prospective study among United States adults. Circulation. 2010;121(22):2398-2406. 11. Malik VS, Popkin BM, Bray GA, Despres JP, HU FB. Sugar-sweetened beverages, obesity, type 2 diabetes mellitus, and cardiovascular disease risk. Circulation. 2010;121(11):1356-1364.
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