Sugar-Sweetened Beverages Consumption: Evidence for the effects on obesity David S. Ludwig, MD, PhD 1
Presenter Disclosure Information David S. Ludwig, MD, PhD Sugar-Sweetened Beverages Consumption: Evidence for the effects on obesity FINANCIAL DISCLOSURE: No relevant financial relationship exists 2
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Sugar-Sweetened Beverages Benefits clinically proven superior hydration benefit compared to water Source? Kraft Foods Inc. Wall Street Journal, Oct 31, 2005 4
Sugar-Sweetened Beverages Adverse effects Negative impact on diet quality Obesity Type 2 diabetes Cardiovascular disease Gout Osteoporosis Dental carries Cancer (?) 5
Sugar-Sweetened Beverages & Health Nature of the evidence Physiological mechanisms Cross-sectional observational studies Prospective observational studies Randomized controlled trials Inconsistency in the literature Biological variation Bias arising from conflicts of interest 6
Sugar-Sweetened Beverages & Health Nature of the evidence Physiological mechanisms Cross-sectional observational studies Prospective observational studies Randomized controlled trials Inconsistency in the literature Biological variation Bias arising from conflicts of interest 7
Physiological Mechanisms Numerous, potentially synergistic effects Passive energy consumption when drinking: to satisfy thirst for social purposes Poor satiety value of sugar in liquid form High glycemic load 8
Physiological Mechanisms Liquid vs. Solid There is no clear evidence that sugar consumption per se promotes food intake or obesity in a unique manner Hill & Prentice, AJCN 1995, 62:264S Sugar in liquid form may be less satiating (filling) than sugar in solid form DiMeglio, Mattes Int J Obes 2000;24:794; Pan & Hu, Curr Opin Clin Nutr Metab Care 2011, 14:385-90 9
Energy Intake (kcal/day) Effects of Solid vs. Liquid Sugar Energy Intake from Other Foods and Beverages 2500 2000 Baseline Week 4 1500 1000 500 0 450 Kcal/d Jelly Beans 450 Kcal/d Soda DiMeglio, Mattes Int J Obes 2000;24:794 10
Physiological Mechanisms Glycemic load SSBs may adversely affect food intake and metabolism through their high glycemic index/load 11
Blood Glucose The Glycemic Index A measure of carbohydrate (cho) digestion rate White bread Soy beans 0-0 1 2 3 4 5 Time (hr) Area under the glycemic curve after consumption of 50 g CHO from test food divided by area under curve after 50 g CHO from control food 12
Glucose (mmol/l) Glycemic Index & Hunger Blood glucose 4 3 2 High GI Med GI Low GL 1 0-1 0 1 2 3 4 5 Time (hr) Ludwig. Pediatrics 1999, 103:e261-6 13
Kilocalories Consumed Glycemic Index & Hunger Cumulative Food Intake 1500 1000 500 High GI Med GI Low GL Ludwig. Pediatrics 1999, 103:e261-6 0 1 2 3 4 5 Time (hr) 14
Glycemic Load & Metabolism Methods 39 obese young adults, age 18-40, weight stable 6 months Randomly assigned, parallel design Energy restricted Low or High GL diets intended to produced 10% weight loss over 8 to 12 weeks 15
Glycemic Load & Metabolism Change in resting energy expenditure after weight loss High GL Low GL p <.05 Kcal/d Pereira, Ludwig. JAMA 2004, 292:2482-90 16
Effects of Glycemic Load on Body Weight 773 adults from 8 European countries who initially lost >7% body weight Diet: Low vs high protein; low vs high GI for 26 weeks ad libitum Intervention: Family counseling Diogenes Adult Study, NEJM 2010, 363:2102-13 17
Effects of Glycemic Load on Body Weight (Continued) High GL (low protein, high GI) Medium GL (high protein, high GI) Medium GL (low protein, low GI) Low GL (high protein, low GI) Diogenes Adult Study, NEJM 2010, 363:2102-13 18
Sugar-Sweetened Beverages & Health Nature of the evidence Physiological mechanisms Cross-sectional observational studies Prospective observational studies Randomized controlled trials Inconsistency in the literature Biological variation Bias arising from conflicts of interest 19
Cross-Sectional Studies Adverse effects on energy balance 1810 children participating in the Continuing Survey of Food Intake by Individuals Total energy intake directly associated with SSB intake: 2018 kcal/d for consumers 1830 kcal/d for nonconsumers Harnack et al. JADA 1999, 99:436-41 20
Cross-Sectional Studies Adverse effects on energy balance 3098 children/adolescents in a nationally represented survey (NHANES 2003-4) Using a within subject comparison between 2 days: Each additional serving of SSB corresponded to a net increase of 106 kcal/d Replacing all SSB with water would produce an estimated 235 kcal/d decrease in energy intake Wang et al. Arch Pediatr Adol Med 2009, 163:336-43 21
Cross-Sectional Studies Positive associations with body weight or obesity Gillis & Bar-Or. J Am Coll Nutr 2003, 22:539-45 181 children ages 4 to 16 years, obese and non-obese Nicklas et al. Am J Prev Med 2003, 25:9-16 1,562 children age 10 years in Bogalusa Novotny et al. J Nutr 2004, 134:1905-9 323 girls ages 9 to 14 years at Kaiser Permanente Collison et al. BMC Pub Health 2010, 10:234 9433 adolescents, ages 10 to 19 in Saudi Arabia Francis et al. Public Health Nutr 2009, 12:1106-14 1317 adolescents, ages 15-19 years, in Jamaica 22
Cross-Sectional Studies No association Forshee and Storey. Int J Food Sci Nutr 2003, 54:297 3,311 children ages 6 to 19 years in the Continuing Survey of Food Intake by Individuals Forshee et al. Int J Food Sci Nutr 2004, 55:463 2,216 children ages 12-16 years in NHANES III Valente et al. Pub Health Nutr 2011, 14:127-32 1675 children 5 to 10 year in Portugal elementary schools 23
Sugar-Sweetened Beverages & Health Nature of the evidence Physiological mechanisms Cross-sectional observational studies Prospective observational studies Randomized controlled trials Inconsistency in the literature Biological variation Bias arising from conflicts of interest 24
Prospective Studies Positive association 19 month study of 548 middle school students Diet assessed by a food frequency questionnaire Every additional serving of SSB per day increased risk of obesity by 60% Ludwig, Peterson, Gortmaker. Lancet 2001, 357:505-8 25
Prospective Studies Positive association 10-year study of 141 girls 8 to 12 years SSB was the only snack food associated with BMI Phillips et al. Obes Res 2004, 12:461 26
Prospective Studies Positive association 1-year study of 10,904 children ages 2 to 3 years Children were 2-times more likely to become or remain obese if they drank SSB Walsh et al. Pediatrics 2005, 115:223 27
Prospective Studies Positive association 10-year analysis of 91,249 women in the Nurse s Health Study Weight gain was: greatest among those increasing SSB (about 2.5 lb/year) least among those decreasing SSB (near zero) Among individuals consuming 1 SSB/d, compared to non-consumers, risk for diabetes was increased by 83% Schulze BM et al. JAMA 2004, 292:927-34 28
Prospective Studies Positive association 22-year analysis of 42,883 men in the Health Professional s Follow-up Study Intake of SSB was associated with increased triglycerides, CRP, IL6, TNFr1, TNFr2, Lp(a), leptin decreased HDL cholesterol Individuals in the top vs bottom quartile of SSB consumption had 20% increased risk of coronary heart disease dedoning et al. Circulation, March 12 (epub ahead of print) 29
Sugar-Sweetened Beverages & Health Nature of the evidence Physiological mechanisms Cross-sectional observational studies Prospective observational studies Randomized controlled trials Inconsistency in the literature Biological variation Bias arising from conflicts of interest 30
Randomized Controlled Trials 30 men and women given 3 cups/d SSB or artificially sweetened beverages for 3 weeks Tordoff &Alleva. AJCN 1990, 51:963-9 31
Randomized Controlled Trials 21 overweight men and women given 3 cups/d of SSB or artificially (aspartame) sweetened beverages for 3 weeks. Raben et al. AJCN 2002, 76:721 32
Randomized Controlled Trials Clustered randomized controlled trial, 600 children 7-11 yr Intervention: educational program designed to eliminate all fizzy drinks (including artificially sweetened beverages) Consumption differed between groups by < 2 oz per day No overall difference in BMI Incidence of overweight/obesity significantly lower in the intervention group: 0.2 vs 7.7% James et al. British Med J 2004, 328:1237 33
Randomized Controlled Trials Clustered randomized controlled trial, 1140 students ages 9-12 yr Intervention: educational program designed to decrease SSB Consumption differed between groups by < 2 oz per day No overall difference in BMI Among obese students, BMI decrease 0.4 units (p = 0.11; p = 0.009 for females). Sichieri et al. Public Health Nutr 2009, 12:197-202 34
Randomized Controlled Trials 6-month randomized controlled trial of 103 nonobese and obese adolescents consuming at least 12 oz SSB/d Intervention: delivery of non-calorie-containing beverages to participants homes (to replace SSB) SSB consumption decreased by 82% in the intervention group; no change among controls (p < 0.0001) Ebbeling, Ludwig. Pediatrics 2006, 117:673 35
Randomized Controlled Trials P for interaction with baseline BMI = 0.016 Among those in the heaviest baseline BMI tertile (> 25), BMI was 0.75 kg/m 2 lower, p = 0.03 in the intervention group 36 36
Sugar-Sweetened Beverages & Health Nature of the evidence Physiological mechanisms Cross-sectional observational studies Prospective observational studies Randomized controlled trials Inconsistency in the literature Biological variation Bias arising from conflicts of interest 37
Conflicts of Interest in Beverage Research Background Bias in pharmaceutical research has been the subject of extensively study. Bekelman JE. JAMA 2003, 289:454-465 However, this issue hadn t been systematically examined in the area of nutrition 38
Conflicts of Interest in Beverage Research Aims & methods Primary aim: to examine the relationship between sponsorship and conclusion among scientific articles pertaining to milk, fruit juices and sugar-sweetened beverages over a 5-year period To avoid potential bias in study design, two groups of investigators independently analyzed article conclusions and financial sponsors 206 articles included, of which 111 declared financial sponsorship 39
Conflicts of Interest in Nutrition Research Results: odds ratios The OR of a favorable vs. unfavorable finding regarding the beverage under study was 4 to 8 fold greater, if the study was exclusively funded by industry. 40
Conflicts of Interest in Nutrition Research Another systematic review of bias Meta-analysis of 88 studies involving SSB and health Overall, a strong relationship was found between consumption and body weight, diabetes and several other health outcomes Studies funded by the food industry reported significantly smaller effects than did non-industryfunded studies Vartanian et al. AJPH 2007, 97:667-75 41
Summary of the Evidence Strong evidence for an effect on obesity and related diseases Mechanistic studies provide plausible evidence to suggest that SSB consumption promotes a positive calorie balance and weight gain Cross-sectional studies show both positive and no associations. Limitations include confounding, reverse causality, lack of power Prospective studies report direct associations with weight gain, diabetes and heart disease Data from randomized controlled studies are limited but suggestive 42
Summary of the Evidence Strong evidence for an effect on obesity and related diseases Some of the variability in the literature may arise from bias related to financial conflicts of interest Unresolved issues uniquely susceptible populations? effects of artificially sweetened beverages? 43
A Large-Scale RCT 220 overweight/obese adolescents (ages 13 to 17 yr) who consumed >12 oz sugar-containing beverages/d Intervention: delivery of non-calorie containing beverages for 1 year, with a second year of follow-up Primary endpoint: change in BMI Data collection completed Dec 2011 Participant completion rate > 90% Manuscript under review 44