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Original Investigation |

Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

Quanhe Yang, PhD1; Zefeng Zhang, MD, PhD1; Edward W. Gregg, PhD2; W. Dana Flanders, MD, ScD3; Robert Merritt, MA1; Frank B. Hu, MD, PhD4,5
[+] Author Affiliations
1Division for Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
2Division of Diabetes Control, Centers for Disease Control and Prevention, Atlanta, Georgia
3Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
4Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts
5Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
JAMA Intern Med. 2014;174(4):516-524. doi:10.1001/jamainternmed.2013.13563.
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Importance  Epidemiologic studies have suggested that higher intake of added sugar is associated with cardiovascular disease (CVD) risk factors. Few prospective studies have examined the association of added sugar intake with CVD mortality.

Objective  To examine time trends of added sugar consumption as percentage of daily calories in the United States and investigate the association of this consumption with CVD mortality.

Design, Setting, and Participants  National Health and Nutrition Examination Survey (NHANES, 1988-1994 [III], 1999-2004, and 2005-2010 [n = 31 147]) for the time trend analysis and NHANES III Linked Mortality cohort (1988-2006 [n = 11 733]), a prospective cohort of a nationally representative sample of US adults for the association study.

Main Outcomes and Measures  Cardiovascular disease mortality.

Results  Among US adults, the adjusted mean percentage of daily calories from added sugar increased from 15.7% (95% CI, 15.0%-16.4%) in 1988-1994 to 16.8% (16.0%-17.7%; P = .02) in 1999-2004 and decreased to 14.9% (14.2%-15.5%; P < .001) in 2005-2010. Most adults consumed 10% or more of calories from added sugar (71.4%) and approximately 10% consumed 25% or more in 2005-2010. During a median follow-up period of 14.6 years, we documented 831 CVD deaths during 163 039 person-years. Age-, sex-, and race/ethnicity–adjusted hazard ratios (HRs) of CVD mortality across quintiles of the percentage of daily calories consumed from added sugar were 1.00 (reference), 1.09 (95% CI, 1.05-1.13), 1.23 (1.12-1.34), 1.49 (1.24-1.78), and 2.43 (1.63-3.62; P < .001), respectively. After additional adjustment for sociodemographic, behavioral, and clinical characteristics, HRs were 1.00 (reference), 1.07 (1.02-1.12), 1.18 (1.06-1.31), 1.38 (1.11-1.70), and 2.03 (1.26-3.27; P = .004), respectively. Adjusted HRs were 1.30 (95% CI, 1.09-1.55) and 2.75 (1.40-5.42; P = .004), respectively, comparing participants who consumed 10.0% to 24.9% or 25.0% or more calories from added sugar with those who consumed less than 10.0% of calories from added sugar. These findings were largely consistent across age group, sex, race/ethnicity (except among non-Hispanic blacks), educational attainment, physical activity, health eating index, and body mass index.

Conclusions and Relevance  Most US adults consume more added sugar than is recommended for a healthy diet. We observed a significant relationship between added sugar consumption and increased risk for CVD mortality.

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Figure 1.
Adjusted Hazard Ratio (HR) of the Usual Percentage of Calories From Added Sugar for Cardiovascular Disease Mortality Among US Adults 20 Years or Older: National Health and Nutrition Examination Survey Linked Mortality Files, 1988-2006

Histogram of the distribution of usual percentage of calories from added sugar in the population. Lines show the adjusted HRs from Cox models. Midvalue of quintile 1 (7.4%) was the reference standard. The model was adjusted for age, sex, race/ethnicity, educational attainment, smoking status, alcohol consumption, physical activity level, family history of cardiovascular disease, antihypertensive medication use, Healthy Eating Index score, body mass index, systolic blood pressure, total serum cholesterol, and total calories. Solid line indicates point estimates; dashed lines indicate 95% CIs.

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Figure 2.
Adjusted Hazard Ratio (HR) of Cardiovascular Disease Mortality Comparing Quintile 5 With Quintile 1 of Usual Percentage of Calories From Added Sugar by Selected Characteristics Among US Adults 20 Years or Older: National Health and Nutrition Examination Survey Linked Mortality Files, 1988-2006

For the Healthy Eating Index score, the top 50% or higher included the participants with a score of 63.5 or more; high physical activity included the participants who had moderate intensity to vigorous activities 5 or more times per week. Limit lines indicate 95% CI. Body mass index is calculated as weight in kilograms divided by height in meters squared.

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