High Juice Consumption May Up Mortality Risk

Norra MacReady

May 17, 2019

Numerous studies have shown that sugar-sweetened beverages (SSBs) such as soda and iced tea have a deleterious effect on human health. Now, findings from a large cohort study suggest that 100% fruit juices should be added to that list as well.

In a survey of more than 13,000 adults aged 45 years or older from across the United States, each additional daily 12-ounce serving of fruit juice, independent of other SSBs, was associated with a 24% increase in the risk for all-cause mortality, Lindsay J. Collin, MPH, and coauthors write in an article published online today in JAMA Network Open. Each additional serving of any sugary beverage was associated with an 11% increase in all-cause mortality risk.

The findings suggest that higher consumption of sugary beverages, including naturally sweet fruit juices, "is associated with increased all-cause mortality among older US adults," they warn. Efforts aimed at reducing consumption of SSBs should include fruit juice, they say.

The evidence, although only suggestive, "brings attention to potential adverse effects of SSB vs fruit juice consumption on health," Marta Guasch-Ferré, PhD, and Frank B. Hu, MD, PhD, write in an invited comment about the study.

Many people consider fruit juice to be a healthier alternative to sugary soft drinks, add Guasch-Ferré and Hu, both of the Harvard T. H. Chan School of Public Health, Boston, Massachusetts. However, these drinks "often contain as much sugar and as many calories as SSBs. Although the sugar in 100% fruit juices is naturally occurring rather than added, once metabolized, the biological response is essentially the same."

Collin, of 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 factors contributing to the excess risk for stroke among adults living in the southeastern United States and among black US residents 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. All were at least 45 years of age 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 about their usual consumption of 110 food items during the previous year. Mortality related to all causes and to coronary heart disease (CHD) were the outcomes of interest. Follow-up data collected through 2013 were used in the analysis.

The final cohort for this study consisted of 13,440 individuals, or 49.5% of the total REGARDS sample. The mean 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.

Nearly everyone in the cohort (97.4%) reported consuming some type of sugary beverage. The mean consumption of sugary drinks accounted for 8.4% (SD, 8.3) of total daily energy intake. Of that total, SSBs (excluding fruit juice) accounted for 4.4% (SD, 6.8), and fruit juice accounted for 4% (SD, 6.8).

During the follow-up period, 1000 people died from any cause, including 168 who died from CHD-related causes. Compared with the lowest intake of all sugary drinks, defined as <5% of total energy intake, the hazard 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 adjusting for socioeconomic factors, demographics, diet quality, and physical activity.

After further adjustment for total energy intake, the HR for CHD mortality was 1.31 (95% CI, .86 – 2.00) between the highest and lowest consumers of all sugary drinks.

When sugary beverage consumption was assessed as a continuous variable, the authors found that each additional 12-ounce serving of sugary beverages was associated with an HR for CHD mortality of 1.15 (95% CI, .97 – 1.37) and for all-cause mortality, 1.11 (95% CI, 1.03 – 1.19).

When broken down according to type of drink, the HR associated with CHD mortality for each additional 12 ounces of beverage was 1.11 (95% CI, .90 – 1.39) for SSBs and 1.28 (95% CI, .95 – 1.74) for fruit juices. With regard to all-cause mortality, for SSBs, the HR was 1.06 (95%, .96 – 1.16), and for fruit juices, the HR was 1.24 (95% CI, 1.09 – 1.42).

Study limitations include the relatively small number of deaths that occurred during follow-up, reliance on self-report for estimates of food and beverage consumption, the inability to distinguish among different types of SSBs, such as sweetened teas, and the possibility of other, unmeasured confounders, the authors write.

They authors conclude that although many current program and policy initiatives are focused on reducing consumers' consumption of SSBs, "our results suggest that these efforts should be extended to include fruit juices."

The study authors and Guasch-Ferré have disclosed no relevant financial relationships. Hu has received grants from the National Institutes of Health, research support from the California Walnut Commission, honoraria from Metagenics, Inc, and Standard Process, Inc, for lectures, and honoraria from Diet Quality Photo Navigation outside the submitted work.

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

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