Friends with drinks at table

Sugars-sweetened beverages and health

This content has been reviewed by Assistant Professor Laura Chiavaroli, University of Toronto, Canada.

Sugars-sweetened beverages (SSBs)

SSBs are commonly defined as drinks which are sweetened with added sugars, such as carbonated and non-carbonated regular soft drinks, juice drinks, iced-teas, sports drinks, energy drinks, and concentrated forms of soft/juice drinks which require dilution with water prior to consumption. Definitions sometimes include sugars-sweetened tea/coffee, sugars-sweetened dairy drinks, and/or 100% fruit juice. 

Row of drinks

Sugars, SSBs & health

SSBs are frequently researched for their possible effects on health and the European Food Safety Authority (EFSA) has noted that much of the evidence on sugars & health is based on studies using SSBs. This research is often looking at high intakes of SSBs, providing over 20% of an individual’s daily calorie intake (20%E) or 100 g/d of free sugars. To put this in perspective, one 355 mL (12 fluid ounces) can of a regular soft drink provides around 40 g of free sugars. At a population level, average daily intakes of free sugars from SSBs in adults varies between 9 - 40 g in European countries (1). The average contribution of regular soft drinks to the intake of total calories in Canadian adults, as an example, ranges from 0.9 – 2.2%E (2). In Canadian consumers of soft drinks (10-24% of adults), the intake ranges from approximately 1 to 1.5 355mL cans per day, providing ~40-60g of free sugars (2). Furthermore, a crude global estimate of average intakes of free sugars (from foods and beverages) is 11%E (3). Thus, much of the research on SSBs is carried out at levels of intake much above usual intake (1).

SSBs intake and risk of obesity and chronic disease

There is evidence to suggest high intakes of SSBs are linked to increased risk of obesity (1,4–7). SSBs, like any food or drink that provides calories (energy), can lead to weight gain if consumed excessively. Obesity is a multi-factorial disease and research has shown that people who drink lots of SSBs are more likely to have an “unhealthy diet” and exercise less, which can also contribute to obesity (8–10).

High intakes of SSBs have been linked to increased risk of a number of other health problems (1,11–14), including:

  • Type 2 diabetes mellitus
  • Heart disease 
  • Liver disease

Weight gain and living with obesity can increase the risk of type 2 diabetes mellitus, heart disease and non-alcoholic fatty liver disease. It’s not clear whether links between drinking SSBs and these health conditions are due to overall excess calorie (energy) intake, other ‘less healthy’ diet and lifestyle factors that are common in individuals who drink high amounts of SSBs, and/or due to the sugars component of SSBs (8–10,15). EFSA noted in their recent scientific opinion that most of the evidence comes from observational studies in which it is difficult to control for the role of excess calorie intake and the effect of other lifestyle factors (1). EFSA also found these studies often categorise SSBs differently using varying definitions, are based on high intakes of SSBs, use inaccurate methods to measure SSB intakes and do not have enough information to determine the sugar content of the SSBs. This makes it difficult to draw conclusions across the evidence base (1). 

Holding can on beach

Differences by food source

It has been suggested by researchers at The University of Toronto, that the form in which sugars are consumed (e.g., foods vs beverages) may be important when looking at the risk of obesity and other health outcomes (16). The researchers conducted a scientific review of the evidence on this topic and found consumption of sugars in the form of SSBs and fruit drinks led to increases in body weight when consumed as excess calories, while those in foods did not. Some sources of sugars, like fruit and dried fruit, led to reductions in body weight (16). These differences according to food source, were similar across scientific reviews on other health risk factors, like blood pressure, blood glucose control, markers of liver disease, and inflammation (13,17–19).
Girl with drink

Feelings of fullness

It is thought these differences by food source may be because the calories from sugars in the form of beverages are consumed and absorbed by the body at a faster rate, and produce a lower sensation of fullness, compared to when consumed in foods (20). This may lead to a faster recurring feeling of hunger, resulting in an increased calorie intake at subsequent meals, compared to when calorie matched foods are consumed. Reviews of short-term intervention studies generally provide support for this hypothesis and have shown that sugars consumed within foods are more satiating (filling) than those consumed within beverages (21–23). However, slightly longer duration intervention studies do not show clear differences on body weight between sugars in beverages compared to in foods (24,25). More research is needed before a consensus can be reached.

Cancer 

Associations between SSB intake and risk of cancer have been observed. However, leading cancer organisations, such as the World Cancer Research Fund (WCRF) and American Institute of Cancer Research (AICR), agree that SSB intake is not directly linked with cancer risk (26). Instead, they state that it is likely that the indirect link between SSB intake and risk of some cancers is mainly related to increased risk of obesity (27). Obesity is a major risk factor for many different cancer types. The WCRF recommend limiting SSBs as “there is convincing evidence that the consumption of SSBs is a cause of weight gain, overweight and obesity”, which is linked to increased risk of obesity-related cancers (28).

Dental caries 

In reviewing the evidence, the UK Scientific Advisory Committee on Nutrition found limited observational evidence that shows the more frequently SSB are consumed (based on number of drinking occasions, rather than total volume of SSBs per day), the higher the risk of dental caries (29). However, the review conducted by EFSA concluded there is very limited evidence suggesting that the amount of SSB intake may be linked with an increased risk of dental caries (1). EFSA acknowledges that the link between sugars intake and dental caries is likely to be influenced by oral hygiene and the use of fluoride (1).

Man in shopping aisle looking at 2 drink bottles

Fructose

In a few countries, high fructose corn syrup (HFCS, also known as glucose-fructose syrup and isoglucose) is used as the sweetening agent in some SSBs. HFCS is derived from corn starch and contains both glucose and fructose. Unlike sucrose (table sugar), the glucose and fructose in HFCS are not bound together but they are still processed in the same way by the body. There have been media reports that HFCS, and fructose in particular, increases the risk of obesity, non-alcoholic fatty liver disease, and diabetes. However, these reports are mainly based on animal studies and some overfeeding trials in humans, where the levels of fructose given are much greater than usual population intakes. Reviews of the evidence, conducted by researchers at The University of Toronto, suggests that higher quality research, at typical intakes in the diet, does not support these concerns (13,16,18,19,30,31). This research suggests it’s the excess calories in the diet which may increase the risk of weight gain and other associated health problems, rather than sugars or the type of sugar per se (16,30,31).

References

  1. EFSA Panel on Nutrition, Novel Foods and Food Allergens (NDA), Turck D, Bohn T, Castenmiller J, de Henauw S, Hirsch-Ernst KI, et al. Tolerable upper intake level for dietary sugars. EFSA Journal. 2022;20(2):e07074. 
  2. Government of Canada. Changes in beverage consumption in Canada. 2019. https://www.doi.org/10.25318/82-003-x201900700003-eng
  3. Walton J, Bell H, Re R, Nugent AP. Current perspectives on global sugars consumption: definitions, recommendations, population intakes, challenges and future direction. Nutr Res Rev. 2021 Aug 9;1–62. 
  4. Dietary Guidelines Advisory Committee. Scientific Report of the 2020 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Agriculture and Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service; 2020 Jul. 
  5. Nguyen M, Jarvis SE, Tinajero MG, Yu J, Chiavaroli L, Mejia SB, et al. Sugar-sweetened beverage consumption and weight gain in children and adults: a systematic review and meta-analysis of prospective cohort studies and randomized controlled trials. Am J Clin Nutr. 2023 Jan;117(1):160–74. 
  6. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013 Oct;98(4):1084–102. 
  7. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ. 2013 Jan 15;346:e7492. 
  8. Leme AC, Ferrari G, Fisberg RM, Kovalskys I, Gómez G, Cortes LY, et al. Co-Occurrence and Clustering of Sedentary Behaviors, Diet, Sugar-Sweetened Beverages, and Alcohol Intake among Adolescents and Adults: The Latin American Nutrition and Health Study (ELANS). Nutrients. 2021 May 26;13(6). 
  9. Arsenault BJ, Lamarche B, Després JP. Targeting Overconsumption of Sugar-Sweetened Beverages vs. Overall Poor Diet Quality for Cardiometabolic Diseases Risk Prevention: Place Your Bets! Nutrients. 2017 Jun 13;9(6):E600. 
  10. Mello GT de, Lopes MVV, Minatto G, Costa RM da, Matias TS, Guerra PH, et al. Clustering of Physical Activity, Diet and Sedentary Behavior among Youth from Low-, Middle-, and High-Income Countries: A Scoping Review. Int J Environ Res Public Health. 2021 Oct 17;18(20):10924. 
  11. Li B, Yan N, Jiang H, Cui M, Wu M, Wang L, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages and fruit juices and risk of type 2 diabetes, hypertension, cardiovascular disease, and mortality: A meta-analysis. Front Nutr. 2023;10:1019534. 
  12. Yang B, Glenn AJ, Liu Q, Madsen T, Allison MA, Shikany JM, et al. Added Sugar, Sugar-Sweetened Beverages, and Artificially Sweetened Beverages and Risk of Cardiovascular Disease: Findings from the Women’s Health Initiative and a Network Meta-Analysis of Prospective Studies. Nutrients. 2022 Oct 11;14(20):4226. 
  13. Lee D, Chiavaroli L, Ayoub-Charette S, Khan TA, Zurbau A, Au-Yeung F, et al. Important Food Sources of Fructose-Containing Sugars and Non-Alcoholic Fatty Liver Disease: A Systematic Review and Meta-Analysis of Controlled Trials. Nutrients. 2022 Jul 12;14(14):2846. 
  14. Tsilas CS, Souza RJ de, Mejia SB, Mirrahimi A, Cozma AI, Jayalath VH, et al. Relation of total sugars, fructose and sucrose with incident type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies. CMAJ. 2017 May 23;189(20):E711–20. 
  15. Yan RR, Bun Chan C, Chun Yu Louie J. Current World Health Organization recommendation to reduce free sugar intake from all sources to below 10% of daily energy intake for supporting overall health is not well-supported by available evidence. Am J Clin Nutr. 2022 Apr 5;nqac084. 
  16. Chiavaroli L, Cheung A, Ayoub-Charette S, Ahmed A, Lee D, Au-Yeung F, et al. Important food sources of fructose-containing sugars and adiposity: A systematic review and meta-analysis of controlled feeding trials. Am J Clin Nutr. 2023 Apr;117(4):741–65. 
  17. Liu Q, Chiavaroli L, Ayoub-Charette S, Ahmed A, Khan TA, Au-Yeung F, et al. Fructose-containing food sources and blood pressure: A systematic review and meta-analysis of controlled feeding trials. PLoS One. 2023;18(8):e0264802. 
  18. Choo VL, Viguiliouk E, Blanco Mejia S, Cozma AI, Khan TA, Ha V, et al. Food sources of fructose-containing sugars and glycaemic control: systematic review and meta-analysis of controlled intervention studies. BMJ. 2018 Nov 21;363. 
  19. Qi X, Chiavaroli L, Lee D, Ayoub-Charette S, Khan TA, Au-Yeung F, et al. Effect of Important Food Sources of Fructose-Containing Sugars on Inflammatory Biomarkers: A Systematic Review and Meta-Analysis of Controlled Feeding Trials. Nutrients. 2022 Sep 26;14(19):3986. 
  20. Macdonald IA. Free sugars. Proc Nutr Soc. 2020 Feb;79(1):56–60. 
  21. Almiron-Roig E, Palla L, Guest K, Ricchiuti C, Vint N, Jebb SA, et al. Factors that determine energy compensation: a systematic review of preload studies. Nutr Rev. 2013 Jul;71(7):458–73. 
  22. Appleton KM, Newbury A, Almiron-Roig E, Yeomans MR, Brunstrom JM, de Graaf K, et al. Sensory and physical characteristics of foods that impact food intake without affecting acceptability: Systematic review and meta-analyses. Obes Rev. 2021 Aug;22(8):e13234. 
  23. Stribiţcaia E, Evans CEL, Gibbons C, Blundell J, Sarkar A. Food texture influences on satiety: systematic review and meta-analysis. Sci Rep. 2020 Jul 31;10(1):12929.
  24. Apolzan JW, Carmichael OT, Kirby KM, Ramakrishnapillai SR, Beyl RA, Martin CK. The effects of the form of sugar (solid vs. beverage) on body weight and fMRI activation: A randomized controlled pilot study. PLoS One. 2021;16(5):e0251700.
  25. Te Morenga L, Mallard SR, Ormerod FB. No Effect of Added Sugars in Soft Drink Compared With Sugars in Fruit on Cardiometabolic Risk Factors: Results From a 4-Week, Randomized Controlled Trial. Front Nutr. 2021;8:636275. 
  26. World Cancer Research Fund/American Institute for Cancer Research. Diet, Nutrition, Physical Activity and Cancer: A Global Perspective. Continuous Update Project Expert Report 2018. Report No.: ISBN: 978-1-912259-47-2. 
  27. World Health Organization: Regional Office for Europe. WORLD CANCER REPORT: cancer research for cancer development. IARC; 2020. 
  28. Limit Consumption of Sugar-Sweetened Drinks. American Institute for Cancer Research. https://www.aicr.org/cancer-prevention/recommendations/limit-consumption-of-sugar-sweetened-drinks/
  29. UK Scientific Advisory Committee on Nutrition. Carbohydrates and Health Report. London: TSO; 2015. 
  30. Liu Q, Ayoub-Charette S, Khan TA, Au-Yeung F, Blanco Mejia S, de Souza RJ, et al. Important Food Sources of Fructose-Containing Sugars and Incident Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies. J Am Heart Assoc. 2019 Dec 17;8(24):e010977. 
  31. Chiavaroli L, de Souza RJ, Ha V, Cozma AI, Mirrahimi A, Wang DD, et al. Effect of Fructose on Established Lipid Targets: A Systematic Review and Meta‐Analysis of Controlled Feeding Trials. Journal of the American Heart Association. 4(9):e001700. 

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