Association between added sugar intake and mortality is nonlinear and dependent on sugar source in 2 Swedish population–based prospective cohorts

Abstract

Background Although sugar consumption has been associated with several risk factors for cardiometabolic diseases, evidence for harmful long-term effects is lacking. In addition, most studies have focused on sugar-sweetened beverages (SSBs), not sugar per se. Objective The aim of this study was to examine the associations between added and free sugar intake, intake of different sugar sources, and mortality risk. Methods Two prospective population-based cohorts were examined: the Malmö Diet and Cancer Study (MDCS; n = 24,272), which collected dietary data by combining a food diary, interview, and food-frequency questionnaire (FFQ), and the Northern Swedish Health and Disease Study (NSHDS; n = 24,475), which assessed diet with an FFQ. Sugar intakes defined as both added and free sugar and different sugar sources were examined. The associations with mortality were examined using a multivariable Cox proportional hazards regression. Results Higher sugar consumption was associated with a less favorable lifestyle in general. The lowest mortality risk was found with added sugar intakes between 7.5% and 10% of energy (E%) intake in both cohorts. Intakes >20E% were associated with a 30% increased mortality risk, but increased risks were also found at intakes <5E% [23% in the MDCS and 9% (nonsignificant) in the NSHDS]. Similar U-shaped associations were found for both cardiovascular and cancer mortality in the MDCS. By separately analyzing the different sugar sources, the intake of SSBs was positively associated with mortality, whereas the intake of treats was inversely associated. Conclusions Our findings indicate that a high sugar intake is associated with an increased mortality risk. However, the risk is also increased among low sugar consumers, although they have a more favorable lifestyle in general. In addition, the associations are dependent on the type of sugar source.

Identification of Inflammatory and Disease-Associated Plasma Proteins that Associate with Intake of Added Sugar and Sugar-Sweetened Beverages and Their Role in Type 2 Diabetes Risk

“…In previous analyses of the full MDC cohort, the highest HR for T2D were observed in the lowest quintile of added sugar intake [ 53 ]. Furthermore, U-shaped associations have been observed between added sugar intake (studied in the same six categories as in the present study) and mortality in the full MDC cohort [ 30 ]. The reason for this U-shape is thought to at least partially be due to potential dietary misreporting and reversed causation, where those at high risk, e.g., overweight individuals, have reduced their sugar consumption or at least reported their dietary intakes as if they had.…”

“…Added sugar intake was estimated from the sum of sucrose and monosaccharides, subtracted for the sum of sucrose and monosaccharides naturally occurring in fruit, vegetables and fruit juices. This has been described in detail in a previous publication [ 30 ]. Added sugar intake was investigated as the percentage of non-alcohol energy intake (E%), both as a continuous variable and categorized into six previously studied categories [ 30 ].…”

“…This has been described in detail in a previous publication [ 30 ]. Added sugar intake was investigated as the percentage of non-alcohol energy intake (E%), both as a continuous variable and categorized into six previously studied categories [ 30 ]. The E% intake coming from SSBs was estimated on the assumption that all SSBs have a mean sugar content of 10 g per 100 g, based on that the sugar content in soft drinks varies between 10–13 g/100 g and cordial/squash contains approximately 8 g/100 g sugar.…”

The associations of sugar-sweetened, artificially sweetened and naturally sweet juices with all-cause mortality in 198,285 UK Biobank participants: a prospective cohort study

“…Previous studies on sugar and mortality have produced conflicting results due, in part, to different approaches to measuring sugar intake including total sugar, percentage of energy derived from sugar and added or free sugar. Whilst some studies have suggested an increased risk associated with added sugar [12], others have not [13] or they have found negligible differences in the positive association between both added and free sugars [14]. A number of studies have focused on sugarsweetened beverages.…”

Association between added sugar intake and micronutrient dilution: a cross-sectional study in two adult Swedish populations

“…Added sugar intake was estimated for each individual by totaling the intake of monosaccharides (mainly glucose and fructose) and sucrose from the whole diet and then subtracting the amount of monosaccharides and sucrose from fruits and berries, fruit juice, and vegetables (i.e., the main sources of naturally occurring sugars) [29]. The percentages of nonalcoholic energy intake (%E) for added sugar were calculated, and the populations were stratified into six groups according to their added sugar intake as follows: less than 5%E, 5-7.5%E, 7.5-10%E, 10-15%E, 15-20%E, and greater than 20%E from added sugar.…”