High juice consumption can increase mortality risk

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Numerous studies have shown that sugar-sweetened drinks (SSB) such as soda and iced tea have a deleterious effect on human health. Now, the results of a large cohort study suggest that even 100% fruit juices should be added to that list.

In a survey of over 13,000 adults aged 45 and over from all over the United States, each 12-ounce serving of fruit juice, independent of other SSBs, was associated with a 24% increase in all-cause mortality risk, Lindsay J. Collin, MPH and co-authors write in an article published online today at JAMA Network Open. Each additional portion of any sweetened beverage was associated with an increase in 11% of all-cause mortality risk.

The results suggest that increased consumption of sugary drinks, including naturally sweet fruit juices, "is associated with an increase in all-cause mortality among older US adults," they warn. Efforts to reduce consumption of SSB should include fruit juice, they say.

The evidence, though only suggestive, "draws attention to the potential adverse effects of SSB compared to the consumption of fruit juices on health", Marta Guasch-Ferré, PhD, and Frank B. Hu, MD, PhD, write in an invited comment on the study.

Many people consider fruit juice a healthier alternative to sugary drinks, Guasch-Ferré and Hu, both of Harvard T. H. Chan School of Public Health, Boston, Massachusetts, add. However, these drinks "often contain a lot of sugar and so many SSB calories, even if the sugar in 100% fruit juices is present in nature rather than added, once metabolized, the biological response is essentially the same".

Collin, from the Department of Epidemiology, Emory University, Atlanta, Georgia and colleagues analyzed data from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study, which examined the factors that contribute to the excess risk of stroke between adults living in the southeastern United States and among blacks resident in the United States in general. Half of the participants were randomly recruited from the southeastern United States and the other half were recruited from the rest of the country. Everyone was at least 45 years old at baseline.

Study volunteers were recruited between February 2003 and October 2007. At baseline, each person completed the block 98 food frequency questionnaire, which asks participants for their usual consumption of 110 food items during the previous year. Mortality related to all causes and coronary heart disease (CHD) were the results of interest. In the analysis the follow-up data collected up to 2013 were used.

The final cohort for this study was 13,440 individuals, or 49.5% of the total REGARDS sample. The average age of the participants was 63.6 years (standard deviation (SD), 9.1). Of the participants, 7927 were men (59.3%), 9266 (68.9%) were white and 9482 (70.6%) were overweight or obese.

Almost everyone in the cohort (97.4%) reported consuming a certain type of sugary drink. The average consumption of sweetened beverages represented 8.4% (SD, 8.3) of the total daily energy consumption. Of this total, SSBs (excluding fruit juices) accounted for 4.4% (SD, 6.8) and fruit juice accounted for 4% (SD, 6.8).

During the follow-up period, 1,000 people died of any cause, including 168 deaths from CHD related causes. Compared to the lowest consumption of all sugary drinks, defined as <5% of total energy intake, the risk ratio (HR) for CHD-related mortality associated with a high intake, defined as ≥10 % of energy consumption, was 1.44 (95% confidence interval (CI), .97 – 2.15), and for all-cause mortality, 1.14 (95% CI, .97 – 1.33), after adjustment for socioeconomic factors, demographic data, quality of diet and physical activity.

After further adjustments for total energy intake, the HR for CHD mortality was 1.31 (95% CI, 0.86 – 2.00) among the highest and lowest consumers of all sugary drinks.

When the sugary consumption of beverages was evaluated as a continuous variable, the authors found that each additional portion of 12 ounces of sweetened beverages was associated with an HR for CHD mortality of 1.15 (95% CI, .97-1, 37) and for mortality for all causes 1.11 (95% CI, 1.03-1.19).

When divided according to the type of drink, the CF associated with coronary heart disease mortality for every 12 ounces of extra drink was 1.11 (95% CI, 0.90 – 1.39) for SSB and 1.28 (IC 95%, 0.95 – 1.74) for fruit juices. As regards all-cause mortality, for SSB, the HR was 1.06 (95%, 0.96-1.16) and for fruit juices the HR was 1.24 (95% CI 1.09-1.42).

The limitations of the study include the relatively small number of deaths occurring during follow-up, the self-assessment reliance on estimates of food and drink consumption, the inability to distinguish between different types of SSB , like sweetened teas and the possibility of others, unmetered confounders, the authors write.

The authors conclude that although many current programs and policy initiatives focus on reducing consumers' consumption of SSB, "our results suggest that these efforts should also be extended to fruit juices".

The authors of the study and Guasch-Ferré did not disclose relevant financial reports. Hu received grants from the National Institutes of Health, research support from the California Walnut Commission, honorary from Metagenics, Inc and Standard Process, Inc, for conferences and Diet Quality Photo Navigation fees outside of the work presented.

JAMA Netw Open. Published online 17 May 2019. Full text, Editorial

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