Sugar-sweetened beverage intake associated with adverse changes in HDL-c and triglycerides
Beverage Consumption and Longitudinal Changes in Lipoprotein Concentrations and Incident Dyslipidemia in US Adults: The Framingham Heart Study Clinical importance of urinary sodium excretion in acute heart failure
Introduction and methods
Sugar-sweetened beverages (SSBs), such as sodas, fruit-flavored drinks, sports drinks, and presweetened coffees and teas are a major source of sugar in the diet of US adults and contribute to excess energy intake . Observational studies suggest that there is an association between added sugar intake and CVD risk [2-4]. Furthermore, intervention trials in animals and humans suggest that consumption of large amounts of sugar can induce dyslipidemia [5-7]. 100% fruit juices (FJ) and low-calorie sweetened beverages (LCSB) are used as alternative beverages to SSBs. Randomized controlled trials and observational studies have examined the association between LCSB [8-10] and FJ [11,12] consumption and CVD, but evidence is mixed. This study aimed to examine the association of SSB, LCSB and FJ consumption with longitudinal changes in concentrations of triglyceride, LDL-c, HDL-c and non-HDL-c concentrations.
The current study used data from the Framingham Offspring Study (FOS, mean age 64.8±9.8 years)  and Generation Three (GEN3, mean age 40.3±8.8 years)  cohorts. Mean follow-up was 12.5 years. In each cohort, participants underwent physical examination and standard laboratory tests. Participants provided information about their diet, lifestyle, medical history and demographics via standard questionnaires. HDL-c, triglyceride and total cholesterol (TC) concentrations were measured in fasting blood samples. LDL-c concentrations were calculated according to the Friedewald equation (LDL-c=TG-HDL-c-triglyceride/5). The effect of recent and cumulative beverage intake on development of dyslipidemia was examined using data from the FOS cohort at examinations 5 (1991-1995), 6(1995-1998), 7 (1998-2001) 9 (2005-2008) and 9 (2011-2014). Dyslipidemia was defined as LDL-c concentrations ≥160 mg/dL or use of LDL-c-lowering medications; HDL-c concentrations <40 mg/dL in men or <50 mg/dL in women; triglyceride concentrations ≥175 mg/dL; and non–HDL-c concentrations ≥190 mg/dL or use of LDL-c-lowering medications. Beverage intakes were grouped into 5 intake categories: <1 serving (12 fl oz for SSB and LCSB and 8 fl oz for FJ) per month, 1-4 servings per month, 1-2 servings per week, 3-7 servings per week, >1 serving per day. Recent beverage intake was defined as intake at one examination before development of dyslipidemia and cumulative beverage intake as the average beverage intake during the period before development of dyslipidemia.
- After multivariable adjustment, participants in the highest category of SSB intake (>1 serving per day) had a 1.6 mg/dL lower mean 4-year change in HDL-c concentrations and a 4.4 mg/dL higher mean 4-year change in triglyceride concentrations compared to those in the lowest category of SSB intake (<1 serving per month) (β±standard error (SE):-1.6±0.4 mg/dL, P for trend <0.0001 for HDL-c, and β±SE:-4.4±2.2 mg/dL, P for trend=0.003 for triglyceride).
- Participants in the highest category of LCSB intake had a 0.7 mg/dL lower mean 4-year change in HDL-c concentrations than those in the lowest intake category (β±SE:-0.7±0.2 mg/dL, P for trend=0.001).
- The highest category of recent SSB consumers had 98% higher incidence of low HDL-c and 53% higher incidence of high triglyceride compared to those in the lowest category of SSB intake (HR 1.98, 95%CI 1.20-3.28, P for trend=0.01 for HDL-c and HR 1.53, 95%CI 1.01-2.31, P for trend=0.004 for triglyceride). For cumulative SSB intake, the risk was attenuated to nonsignificant for incidence of low HDL-c and high triglyceride.
- The highest category of recent LCSB consumers had a 40% higher incidence of high non-HDL-c and 27% higher incidence of high LDL-c compared with the lowest category of LCSB consumers (HR 1.40, 95%CI, 1.17-1.69, P for trend=0.0002 for non-HDL-c, and HR 1.27, 95%CI 1.05-1.53, P for trend=0.01 for LDL-c). For cumulative LCSB intake, these associations were attenuated to nonsignificant.
- No significant associations were found between risk of dyslipidemia and intake of FJ.
SSB consumption was associated with adverse changes in HDL-c and triglyceride. High recent SSB intake was associated with higher incidence of low HDL-c and high triglycerides and high recent LCSB consumption was associated with higher incidence of high non-HDL-c and high LDL-c compared to low consumption of these beverages. No increased risk was found for cumulative SSB and LCSB intake and no significant associations were found between risk of dyslipidemia and intake of FJ.
Daily intake of added sugars should not exceed 10% of the total daily calories according to the 2015-2020 Dietary Guidelines for Americans . Although SSB consumption has decreased in the US during the past decade, SSB consumption remains high [16,17]. Kuklina and Park note in their editorial comment  that there is substantial evidence available that supports limiting SSB intake for health benefits including reduced risk of obesity, T2DM and CVD . The current study of Haslam et al. provides evidence on the adverse effects of SSBs on lipid profile. Regular SSB consumption was associated with a decrease in HDL-c and increase in triglycerides and regular LCSB consumption was associated with an increase in LDL-c and non-HDL-c compared to low consumption of these beverages. Kuklina and Park note that the sugar content in LCSB can vary from 0 to 9.99g per serving, which complicates the interpretation of results.
No significant associations were found between consumption of FJ and lipid profile. A review article previously reported that the effects of FJ on lipids are inconsistent . Kuklina and Park comment that FJ can be easily overconsumed and can therefore contribute to energy imbalance by increasing the calorie intake . Thus, a limited amount of FJ can be consumed, but whole fruits are a better choice, as FJ has no nutritional benefits over whole fruits .
Several factors have been identified as contributors to the consumption of SSBs, such as exposure to advertisements, availability of SSBs in schools or at home, and parental consumption of SSBs [21-24]. A Cochrane review investigated the evidence for environmental interventions to reduce SSB intake . These interventions included consumer labels on SSBs promoting healthier beverages in supermarkets, increasing prices on SSBs in restaurants, stores and fitness centers (compared with other drinks, such as water), and easier access to healthier beverages at home. Kuklina and Park conclude that implementation of interventions to address SSB consumption requires a collaborative and multisectoral approach.