Naveed Saleh, MD, MS, for MDLinx | May 23, 2019
You probably know that most sugary drinks—including sugar-sweetened beverages (SSBs) like soda, soft drinks, and fruit-flavored drinks—are bad for you. But what about 100% fruit juice, another type of sugary drink?
Although there have been some declines in sugar consumption in recent years, people still drink a lot of sugary drinks and consume a lot of sugar in the diet. In public health campaigns, less attention has been paid to 100% fruit juices, which many consider to be healthy.
In a new study, researchers found that 100% fruit juice and sugary beverages equally increased risk of early mortality.
Just sugar and water
In a large cohort study (n=13,440; mean age: 63.6 years; 59.3% men; 70.8% overweight or obese) published in JAMA Network Open, researchers examined the link between death and the consumption of SSBs and 100% fruit juices, both alone and in combination.
Patients with known coronary heart disease (CHD), stroke, or diabetes at baseline were excluded. The researchers determined the consumption of SSBs and 100% fruit juice using food-frequency questionnaires, and patients were followed up every 6 months for an average of 6 years.
Almost all the members of the study population (97.4%) reported drinking some type of sugary beverage, with 10,873 subjects (80.9%) drinking SSBs and 12,637 subjects (94.0%) drinking fruit juices. Average sugary beverage consumption was 8.4% of total energy intake per day.
During follow-up, 168 subjects died from CHD-related causes, and 1,000 died from any cause. The risk-adjusted hazard ratio—a measure of instantaneous risk—was 1.44% (95% CI: 0.97-1.33) for death from CHD and 1.14% (95% CI: 0.97-1.33) for all-cause mortality in subjects who had the highest amount of sugar intake.
The authors concluded that increased consumption of sugary beverages, including 100% fruit juices, upped all-cause mortality in older adults.
“Fruit juices are still widely perceived as a healthier option than SSBs. However, they 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,” wrote Marta Guasch-Ferré, PhD, and Frank B. Hu, MD, PhD, Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, in an invited commentary.
While 100% fruit juices do contain vitamins and phytonutrients, which make them slightly healthier than most SSBs, the main ingredients in both are sugar and water. These sugars are either a mix of the monosaccharides glucose and fructose or the disaccharide sucrose, which is metabolized into equal parts fructose and glucose.
Notably, the authors doubted that obesity itself was the mechanism that led to higher risks of CHD mortality and overall mortality.
“Given that the higher risk with sugary beverage consumption occurs even when controlling for [body mass index] and the lack of significant interaction between sugary beverage consumption and weight status, our findings suggest that other factors are at play,” they wrote. “Sugary beverages increase insulin resistance and CHD mortality risk independent of adiposity. Insulin resistance is known to increase triglyceride levels and atherosclerosis, which are important cardiovascular disease risk factors.”
The authors suggested that, given the dietary repercussions of all types of sugary drinks, public health efforts should be expanded to target not only sugar and SSBs, but also fruit juices.
Too much sugar
The only other study on the association between mortality risk and sugar consumption was conducted by researchers at the CDC and published in JAMA Internal Medicine. The researchers mined data from the National Health and Nutrition Examination Survey and found a higher risk of cardiac mortality among US adults who ate more sugar.
The adjusted mean percentage of daily calories due to added sugar went up from 15.7% in 1988-1994 to 16.8% in 1999-2004, and then dropped back down to 14.9% in 2005-2010. In total, 71.4% of US adults consumed 10% or more calories from added sugar. Furthermore, 10% of US adults consumed 25% or greater calories from added sugar in 2005-2010.
Age-, sex-, and race/ethnicity–adjusted hazard ratios of cardiovascular disease mortality spanning quintiles of the percentage of daily calories ingested 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 controlling for sociodemographic, behavioral, and clinical factors, hazard ratios 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=0.004), respectively.
“Most US adults consume more added sugar than is recommended for a healthy diet,” concluded the authors. “We observed a significant relationship between added sugar consumption and increased risk for [cardiovascular disease] mortality.”
Keep it in perspective
But does this mean you should avoid fruit juice altogether? Not if it’s your only source of nutrition, says Isabel Maples, MEd, RDN, registered dietitian and spokesperson, Academy of Nutrition and Dietetics, Chicago, IL.
“When eating healthier, don’t be afraid to pour a glass of juice!” she said. “Most children, teens, and adults don’t get the nutrition that they need because they’re not eating enough fruit. Drinking fruit juice can help fill that nutrient gap. Plus, juice tastes good, so people are likely to substitute juice for sugary drinks.”
Maples said it’s true that our bodies digest fruit juice just like sugar-sweetened beverages, but she insists that sugar is not evil. “Not too long ago, fat was food enemy #1. It’s not sugar that is bad—it’s too much added sugar, and it’s how sugar squeezes good nutrition out of the diet because we eat fewer nutrition-packed foods like fruit. For better nutrition, keep the five food groups in balance.”
She added, “When fear, not facts, drive our food decisions, extremes can happen…and suddenly, food is no longer fun. That’s when good nutrition suffers.”
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