Added sugar intake and its associations with incidence of cardiovascular disease

https://www.frontiersin.org/journals/public-health/articles/10.3389/fpubh.2024.1452085/full

by gnabgib • 2 years ago

151 168 2 years ago

jal278• 2 years ago

High intake of sweetened beverages was associated with higher risk for most of the studied outcomes, for which positive linear associations were found. In contrast, a low intake of treats was associated with a higher risk of all the studied outcomes.

Not sure what to make of this -- some kind of other latent explanation (e.g. that many of those with the lowest intake of treats were on a diet due to bad health?).

From the discussion section:

One aspect to take into consideration is however that there is a social tradition of “fika” in Sweden, where people get together with friends, relatives, or coworkers for coffee and pastries (41). Thus, one could hypothesize that the intake of treats is part of many people's everyday lives without necessarily being related with overall poor dietary or lifestyle patterns, and that it might be a marker of social life.

lolinder3• 2 years ago

Isn't a simple possible explanation that people who are at high risk of (or already diagnosed with) these diseases make up a disproportionate chunk of the lowest sweets consumption bracket, simply because they're the ones who are actively restricting intake on advice from doctors?

I'd naively expect most healthy people to fall in the second-to-lowest bracket—they're not actively restricting, but they don't have the pervasive bad habits of the highest consumers.

kristjansson• 2 years ago

This is exactly what happened with the “red wine is good for you” claim

ricardobeat• 2 years ago

That was my first thought as well, but the paper says that after excluding all people with a previous condition, that association remains unchanged. There might be something else, like particular diets, at play.

dylan6042• 2 years ago

Could it be that the type of sugar used in the soft drinks is different than the type of sugar used in baking and where the body processes them differently?

Yes, I'm questioning if high fructose corn syrup is worse for the body than table sugar. From everything I've ever seen, that tends to be the case.

Or could it be that the non-fructose corn syrup artificial sweeteners are having more of a negative impact as people do not limit their in-take of those beverages since there's "no sugars" or "0 calories"?

Wolfenstein98k2• 2 years ago

There is not much evidence that it does any unique harm when you calorie-match it to regular sugar.

analog31• 2 years ago

There might be a dietary difference, even though it seems superficially like there shouldn't be. This is my summary of the reaction from a chemist who did her master's degree in sugar chemistry: "Complex sugars (sucrose) and starches are broken up into glucose and fructose quite efficiently by enzymes in your digestive tract. Only glucose and fructose are absorbed into the bloodstream."

That chemist is my mom. So I'm biased. ;-)

The puzzle is whether table sugar and high fructose corn syrup have different dietary effects, and if they do, why. I don't think it's a settled matter.

normie3000• 2 years ago

Yes, I'm questioning if high fructose corn syrup is worse for the body than table sugar.

Study is from Sweden. I think high fructose corn syrup may be a North American thing.

simmerup2• 2 years ago

There are some people that argue this actually. Dr Fungs book on type 2 diabetes goes into it.

Basically his take is that while glucose can be distributed in the bloodstream, fructose is broken down by the liver. With high intakes of fructose comes an overwhelming of the liver and higher incidence of fatty liver plus visceral fat. And those things are highly associated with bad health outcomes

Worth a read if you’re interested

chithanh2• 2 years ago

tl;dr It's the acid. Drink only water.

The issue is that soft drinks are generally bad for cardiovascular health, whether sugar sweetened or not.

https://doi.org/10.1001/jamainternmed.2019.2478

Plausible mechanism is that acidic drinks cause tooth enamel degradation, and poor dental health is a known risk factor for cardiovascular disease.

https://doi.org/10.1093/eurheartj/ehy836

infecto3• 2 years ago

We are just making hypothesis here but I doubt its that. HFCS has been looked at a lot and while there are amounts of people that think it can make them sick, I don't believe in normal doses it does harm in the base case.

The easier explanation is that most "treats" are low glycemic as they are paired with a fat. Where with a can of coke you are ingesting 40g of sugar mixed with some flavorings and water.

zug_zug• 2 years ago

that many of those with the lowest intake of treats were on a diet due to bad health

I haven't read this study, but any study that isn't complete garbage normally would examine the to groups across all variables (age, gender, weight, health, etc) and deliberately control for any systematic differences between groups.

tuukkah3• 2 years ago

You can never control for all variables when humans are involved. (You can only control for variables that your data contains.)

EDIT: From the article: "[There's a] need for future research to incorporate more accurate measures, such as urinary sodium excretion, to more precisely assess the impact of sodium intake as a potential confounding factor."

8f2ab37a-ed6c• 2 years ago

Negative linear associations were found between treats intake (pastries, ice cream, chocolate, and sweets) and all outcomes, and between toppings intake (table sugar, honey, jams, and marmalades) and heart failure and aortic stenosis.

Is all I wanted to know, study confirms my beliefs. Back to the pastry shop for me.

Wolfenstein98k2• 2 years ago

1) I always read this publication's name as "Frontier Sin".

2) "Added sugar intake was positively associated with ischemic stroke and abdominal aortic aneurysm, although the highest risks of most outcomes were found in the lowest intake category."

????

devmor3• 2 years ago

Does not surprise me at all - just because too much of something is bad for you does not mean that some amount of it isn’t essential for bodily function.

1209412comb• 2 years ago

highest risks of most outcomes were found in the lowest intake category

If I am reading this right, it means small amount is even worse than a lot of it.

lolinder3• 2 years ago

I wouldn't jump to this conclusion too quickly, because there are a lot of possible confounding factors and possible reverse causality at play here.

For example, it's entirely plausible that being at high risk of any of these diseases would cause people to cut back on their sweetener intake into the lowest consumption bracket, leading to unhealthy individuals showing a bimodal distribution (those who cut back dramatically on advice from doctors and those who have very very bad habits) while healthy people have a more typical curve.

ertgbnm• 2 years ago

This is a common phenomenon for most things because the people in the lowest intake category of a thing are normally there for a very specific reason.

For example, people who don't drink any alcohol are more likely to die than people who drink a little bit. Why? Because people who don't drink at all tend to be those with liver damage or former alcoholics who have already done permanent damage.

I suspect a similar explanation here. People who avoid added sugar probably have other health complications going on that force them into the lowest intake category.

nerdjon• 2 years ago

One of the best things I did for my diet was to try to rein in all of the places that sugar was snuck into my diet so when I want to get a candy bar or a soda I can not feel bad about it.

My best example of this is peanut butter. I love peanut butter but started making my own with just dry roasted unsalted peanuts and a small amount of salt.

Still enjoyed the things I wanted and fully sustainable. Didn’t actually eliminate anything and no “cheat” days.

Somewhat recently I had a PB craving so I got a jar. Was shocked at how sweet it was.

russell_h2• 2 years ago

Does peanut butter often have added sugar? I’ve got Kirkland and Adam’s in my closet and am 99% sure neither lists that on the container.

PaulStatezny2• 2 years ago

Yes, at least in the USA it almost always has added sugar.

MR4D• 2 years ago

You are correct - Kirkland’s has no added sugar. [0]

[0] https://www.nutritionix.com/i/kirkland-signature/organic-pea...

inferiorhuman4• 2 years ago

Peanut butter and mayonnaise both often have added sugar in the United States. You can find brands without but they're less common.

r00fus4• 2 years ago

Any "shelf-stable" or "no-stir" peanut butter (aka Jif brand) will likely contain sweetener and also palm oil.

You don't have to make your own peanut butter but it tastes even better than a good peanut butter like Kirkland/Adams/etc. Some stores allow you to grind nuts on-site (almond/peanut) and charge you for the output.

euroderf• 2 years ago

It gets worse. PB from the UK can have cane sugar and also palm oil.

What I've read is that peanut oil is valuable as an industrial lubricant, so they siphon it off, replace it with palm oil, and then use sugar to obscure the flavor change.

UK PB is NFG.

didibus• 2 years ago

These are such interesting results. The plot only thickens.

    - Sweetened beverage were linked to cardiovascular disease
    - Table sugar, honey, jams, and marmalades were a little linked
    - Pastries, ice cream, chocolate, and sweets were negatively correlated

Certain sugars were good for your heart. Obviously, this is not causation, but it's an interesting finding. I can't wait to learn more.

forgotoldacc• 2 years ago

As a person who loves pastries and ice cream but drinks no sweetened beverages, while I have doubts whenever I see studies that say "XYZ food proven to be healthy", I'm going to hope this is true.

vineyardmike• 2 years ago

I wonder if this is more correlation with the “transport” medium.

Pastries, ice cream, etc are high in fats, and thick, so they may break down and get absorbed by the body slower while soda is just sugar water so it may flood the body faster.

Alternatively, maybe it’s a time-of-day thing? A dessert you eat after a meal means you’re consuming it on a full stomach while a snack is consumed empty.

resoluteteeth• 2 years ago

Pastries, ice cream, etc are high in fats, and thick, so they may break down and get absorbed by the body slower while soda is just sugar water so it may flood the body faster.

It's definitely not impossible this is the reason. Fat massively affects how fast sugar gets absorbed and this is something that seems to not have gotten much attention in terms of nutrition in general despite things like gi index (which just looks at individual foods in their own).

If the thing that makes sugar bad is spiking blood sugar too much, it could be that how/when people consume it isn't being considered enough because of the assumption that it's always bad and needs to be eliminated as much as possible in general and so there's no point in trying to identify situations where it's not as harmful.

But it could also just be some sort of issue with this study.

anon234234208• 2 years ago

https://www.theatlantic.com/magazine/archive/2023/05/ice-cre...

tuukkah3• 2 years ago

Thanks! This nicely sums up an issue with these food-frequency questionaires:

admitting to eating ice cream might correlate with metabolic health

That is, ice cream might well be bad for you but if you experience the bad effects, you might stop admitting that you eat ice cream and thus add an opposite data point in the study.

seizethecheese5• 2 years ago

Ice cream is actually a low glycemic index food. Chocolate is surprisingly low, too.

adastra224• 2 years ago

Last time I made ice cream myself it required an insane amount of table sugar. I tried less sugar and it didn’t have the right consistency. Sugar is needed to keep ice crystals from forming.

If you want GOOD ice cream, you need sugar. Or maybe antifreeze. But I’d rather have the sugar.

vouaobrasil• 2 years ago

I still believe in reducing added sugar intake as much as possible, simply because cardiovascular disease is not the only metric that we should be judging sugar. Eating it less for instance has made my energy levels much more stable. And of course, reduces dental problems.

hombre_fatal2• 2 years ago

I wonder how many HNers accept this evidence but reject the converging lines of evidence across very different study designs (mendelian randomization, prospective cohort, RCTs) that cholesterol (more specifically, apoB) causes heart disease: https://pmc.ncbi.nlm.nih.gov/articles/PMC5837225/

shlant6• 2 years ago

also pay attention to how most of the big names who discount the causality of LDL regularly criticize questionnaire-based studies (or Nutritional Epidemiology as a whole), but only when it goes against their personal beliefs.

hombre_fatal2• 2 years ago

True, it's a common theme. But even someone who dies on the hill of FFQs has to contend with mendelian randomization and controlled trials.

AnthonBerg• 2 years ago

Thanks for the paper!

For other readers: To expand on this, the paper in the parent comment is “Low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. Evidence from genetic, epidemiologic, and clinical studies. A consensus statement from the European Atherosclerosis Society Consensus Panel” (2017) – https://pmc.ncbi.nlm.nih.gov/articles/PMC5837225/

It refers to a second then-upcoming publication, which I believe is this one:

”Low-density lipoproteins cause atherosclerotic cardiovascular disease: pathophysiological, genetic, and therapeutic insights: a consensus statement from the European Atherosclerosis Society Consensus Panel” (2020) – https://academic.oup.com/eurheartj/article/41/24/2313/573522...

The difference between the titles: The 2017 paper discusses genetic, epidemiologic, and clinical studies and the 2020 one looks at pathophysiological, genetic, and therapeutic insights.

(Personally, I’m in the pathophysiology-and-molecular-biology-or-GTFO camp. And these papers are good to have.)

Thanks again! Just thought I’d share this second paper as I’d gone to look for it anyway.

erie• 2 years ago

Is it the type of added sugar that matters more, because I think they use the cheapest sugars to maximize their profits. But it is not that simple. 'Naturally occurring sugars in fruits and vegetables come with fiber, vitamins, and minerals, which can mitigate some of the negative effects3 Added sugars, whether from table sugar or other sources, provide empty calories without nutritional benefits Sweeteners like fruit juice, honey, molasses and maple syrup contain natural sugar and have some nutritional benefits. Fruit has fiber, vitamins and antioxidants. Even raw honey and maple syrup can contain antioxidants and minerals like iron, zinc, calcium and potassium. https://www.hopkinsmedicine.org/health/wellness-and-preventi...

soramimo• 2 years ago

My kid goes to school in LA. While in theory it's great that they get free food (breakfast, lunches etc), however, I'm absolutely shocked by how much sugar is in everything they offer to kids, in particular for breakfast.

fud101• 2 years ago

I believe it. What if you take sugar around and during exercise for performance reasons? Is that still bad or not? I have 30g sugar powder (gatorade).

0_____0• 2 years ago

I have this question as well. I drink hi-carb beverages during exercise (had 200g of carb on the bike yesterday). I replace calories at or below parity.

I suspect the benefits of cardio outweigh the issues introduced by sugar, but I don't have the knowledge base to do anything more than speculate.

Etheryte• 2 years ago

I've spent some time living in Sweden and I think there's a number of important details here that are not sufficiently highlighted that can radically change how to interpret the results. Swedes have a tradition of eating candy once a week on Saturdays. It's incredibly common for them to not have candy all week, then go buy an assortment bag on Saturday, eat it all, and then not have any again for a week. We don't know how this affects health outcomes compared to say, having a bit of candy every day, the glycemic load profiles will be widely different and we don't know if that matters or not.

Fika, a coffee break with pastries, is a very strong cultural phenomenon. The pastries Swedes have are generally of very high quality and many of them also contain a considerable amount of fat, which as we know, helps buffer glycemic load. While it's mentioned in the study in passing, I think it should instead be one of the core focus points, it's hard to assess the effect of this as opposed to plain added sugar.

And lastly, Swedes are very outdoorsy people. On any day of the week, you can see people strolling on nature trails, of which there are plenty, and spending a lot of time active in general. I would not be surprised if a large part of the health outcomes we see in statistics can be attributed to variance in this.

So to summarize, while these results are interesting, I think there are too many hidden influences here that are not controlled for to really generalize these results in any way.

ecmascript• 2 years ago

As a swede myself I agree somewhat but also I don't think what you're saying is the case anymore, even if it used to be.

Today I think swedes in general consume a lot more sugar and much more in a super processed way that we used to. The culture of only eating candy on saturdays is probably alive and kicking among many children but I think isn't that strong anymore with grown ups. A lot of swedes, including myself, struggle with overweight and I think it is mostly how the food culture has changed to go from european to american inspired.

It's basically impossible to find a restaurant close to a highway that doesn't serve ultra processed food that is cooked in some other kitchen far away or simply fast food where it used to be common place to have basically home cooked meals everywhere you went. Now it's mostly low quality crap food just like the USA.

Also the pasteries to the fikas have changed to be more processed. Everything is made with vegetable oil instead of butter etc. Even things that are supposed to be healthy like yoghurt and similar things are filled up with thickener additives or unnecessary added sugars.

Unfortunately Sweden goes along to be more and more americanized (especially food-wise) and I think it sucks. I wish Sweden would be more like the rest of europe and keep it's food culture.

TL;DR: It used to be like the OP said, but it isn't anymore. It is hard to eat healthy because manufacturer keep pushing so much crap in their products and the availability of crappy food items is just insane.

donatj• 2 years ago

About ten years ago I gave up sugary sodas "for my health" at the behest of my doctor. Almost immediately, I gained a pretty significant amount of weight, rather than losing any. The opposite of what I was told would happen.

I am near certain that the rest of my diet didn't shift in any significant fashion, certainly not enough to replace the caloric intake of 2 to 3 sodas per day and the soda itself was largely replaced with black coffee.

Anyway I don't know what to take from this. I have not gone back to drinking soda, and I never really lost that weight. I suspect that our diets might be more complex than we realize though. I am not a doctor, your mileage may vary.

CharlieDigital7• 2 years ago

I didn't buy this at all.

Weight is a function of calories in and calories out.

If you removed the calories from sugary drinks from your diet and kept the same level of activity, you will lose weight. Conversely, if you replaced those calories or reduced your activity, you will maintain weight.

More than likely you unconsciously compensated for the loss of calories elsewhere in your diet.

dbspin6• 2 years ago

I see this repeated all the time on Hackernews and this is absolutely not the case. Aging, gut microbiome changes and an enormous variety of medications can directly induce weight gain - while diet and exercise remain the same.

Pooge11• 2 years ago

Experts like Dr Giles Yeo would disagree with you on the subject.

Processed food contributes more to weight-gain than would the same amount (in terms of calories) of a non-processed one.

Increasing physical activity has NOT shown that it's a good way to lose weight. Being mindful of what you eat, on the other hand...

A friend told me he wouldn't eat nuts because they are too caloric... ????

scythe2• 2 years ago

the soda itself was largely replaced with black coffee.

As unreliable as Internet medical advice always is, am I to interpret that you're drinking coffee at all hours of the day? Sleep disturbances can lead to all sorts of new problems. Coffee has much more caffeine than soda or any common tea. Switch to something else after noon and see if it doesn't help.

AuryGlenz2• 2 years ago

I drink a can of pop every day as I e found it helps significantly with my IBS. Theoretically it should do the opposite, but apparently my gut micro biome calms down with it.

Perhaps it was something along those lines for you.

maerF0x0• 2 years ago

Study is loaded with confounding factors, and problems relating it as general advice vs cohort: here's a bunch quickly of the top of head, simply for discussion's sake -- not as a direct criticism of the authors / study.

Questionnaire-based diet and lifestyle assessments were administered in 1997 and 2009

These kinds of studies are not good because of a number of factors -- Morality of foods (people often answer questionaires with ideals or what they "ought" rather than fact), People are very bad at estimating their intakes, the data is ~15 yrs ago meaning lots of things can change in the interim

One aspect to take into consideration is however that there is a social tradition of “fika” in Sweden, where people get together with friends, relatives, or coworkers for coffee and pastries (41). Thus, one could hypothesize that the intake of treats is part of many people's everyday lives without necessarily being related with overall poor dietary or lifestyle patterns, and that it might be a marker of social life. Consumption of sweetened beverages, one the other hand, has been linked to lower overall dietary quality (42).

Note that the positive associations were correlated with a _social_ form of eating. We already know folks with strong social connections, and distracting ways to slow life and eating, have better health outcomes. Also consider the zero sum form of eating whereby 100 calories of sugary beverage crowds out 100 calories of nutrient dense food (eg: broccoli). My own personal bias is that this is why vegetarians enjoy some health benefits -- they're simply eating a lot more vegetables (and not because meats are themselves deleterious).

No mention of adiposity (body fat percentage)

A person with low and stable fat% is likely to have a very different response to sugars than someone with a high fat% (insulin resistance) and instability (yoyo-ing seems to matter albeit unclear how)

Cohort

Unless you're a Swede of the average genetic profile ~97-09 then there's a gradient of issues related to your differences.

Added sugar intake and its associations with incidence of cardiovascular disease

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