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Original Investigation
September 3, 2019

Association Between Soft Drink Consumption and Mortality in 10 European Countries

Author Affiliations
  • 1School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland
  • 2School of Agriculture and Food Science, University College Dublin, Dublin, Ireland
  • 3Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France
  • 4Instituto de Investigación Sanitaria Illes Balears (IdISBa), University Hospital of Son Espases, Palma de Mallorca, Spain
  • 5CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Madrid, Spain
  • 6School of Public Health, MRC-PHE Centre for Environment and Health, Imperial College London, London, United Kingdom
  • 7Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
  • 8CESP, Faculté de Médecine, Université Paris-Sud, Faculté de Médecine, UVSQ, INSERM, Université Paris-Saclay, Villejuif, France
  • 9Gustave Roussy, F-94805, Villejuif, France
  • 10German Cancer Research Center (DKFZ), Division of Cancer Epidemiology, Heidelberg, Germany
  • 11Department of Epidemiology, German Institute of Human Nutrition, Potsdam-Rehbrücke, Germany
  • 12Nutrition, Immunity and Metabolism Start-up Lab, Department of Epidemiology, Potsdam-Rehbrücke, Germany
  • 13Danish Cancer Society Research Center, Copenhagen, Denmark
  • 14Department of Public Health, Aarhus University, Aarhus, Denmark
  • 15Office of the Director, International Agency for Research on Cancer, Lyon, France
  • 16Department of Community Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway
  • 17Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway
  • 18Public Health Directorate, Asturias, Spain
  • 19Unit of Nutrition and Cancer, Cancer Epidemiology Research Program, Catalan Institute of Oncology-IDIBELL, L’Hospitalet de Llobregat, Barcelona, Spain
  • 20Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitaria Granada, Granada, Spain
  • 21CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
  • 22Public Health Division of Gipuzkoa, BioDonostia Research Institute, San Sebastian, Spain
  • 23Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain
  • 24Navarra Public Health Institute, Pamplona, Spain
  • 25IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
  • 26University of Cambridge School of Clinical Medicine, Clinical Gerontology Unit, Addenbrooke’s Hospital, Cambridge, United Kingdom
  • 27Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
  • 28Hellenic Health Foundation, Athens, Greece
  • 29WHO Collaborating Center for Nutrition and Health, Unit of Nutritional Epidemiology and Nutrition in Public Health, Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
  • 30Pulmonary Medicine Department, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Haidari, Greece
  • 31Cancer Risk Factors and Life-Style Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network—ISPRO, Florence, Italy
  • 32Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
  • 33Cancer Registry and Histopathology Department, Civic—M. P. Arezzo Hospital, ASP Ragusa, Ragusa, Italy
  • 34Unit of Cancer Epidemiology, Città della Salute e della Scienza University—Hospital and Center for Cancer Prevention (CPO), Turin, Italy
  • 35Dipartimento di Medicina Clinica e Sperimentale, Federico II University, Naples, Italy
  • 36Department for Determinants of Chronic Diseases (DCD), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
  • 37Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, the Netherlands
  • 38Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Pantai Valley, Kuala Lumpur, Malaysia
  • 39Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
  • 40Environmental Epidemiology, Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, the Netherlands
  • 41Nutritional Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden
  • 42Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden
  • 43Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
JAMA Intern Med. Published online September 3, 2019. doi:10.1001/jamainternmed.2019.2478
Key Points

Question  Is regular consumption of soft drinks associated with a greater risk of all-cause and cause-specific mortality?

Findings  In this population-based cohort study of 451 743 individuals from 10 countries in Europe, greater consumption of total, sugar-sweetened, and artificially sweetened soft drinks was associated with a higher risk of all-cause mortality. Consumption of artificially sweetened soft drinks was positively associated with deaths from circulatory diseases, and sugar-sweetened soft drinks were associated with deaths from digestive diseases.

Meaning  Results of this study appear to support ongoing public health measures to reduce the consumption of soft drinks.

Abstract

Importance  Soft drinks are frequently consumed, but whether this consumption is associated with mortality risk is unknown and has been understudied in European populations to date.

Objective  To examine the association between total, sugar-sweetened, and artificially sweetened soft drink consumption and subsequent total and cause-specific mortality.

Design, Setting, and Participants  This population-based cohort study involved participants (n = 451 743 of the full cohort) in the European Prospective Investigation into Cancer and Nutrition (EPIC), an ongoing, large multinational cohort of people from 10 European countries (Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain, Sweden, and the United Kingdom), with participants recruited between January 1, 1992, and December 31, 2000. Excluded participants were those who reported cancer, heart disease, stroke, or diabetes at baseline; those with implausible dietary intake data; and those with missing soft drink consumption or follow-up information. Data analyses were performed from February 1, 2018, to October 1, 2018.

Exposure  Consumption of total, sugar-sweetened, and artificially sweetened soft drinks.

Main Outcomes and Measures  Total mortality and cause-specific mortality. Hazard ratios (HRs) and 95% CIs were estimated using multivariable Cox proportional hazards regression models adjusted for other mortality risk factors.

Results  In total, 521 330 individuals were enrolled. Of this total, 451 743 (86.7%) were included in the study, with a mean (SD) age of 50.8 (9.8) years and with 321 081 women (71.1%). During a mean (range) follow-up of 16.4 (11.1 in Greece to 19.2 in France) years, 41 693 deaths occurred. Higher all-cause mortality was found among participants who consumed 2 or more glasses per day (vs consumers of <1 glass per month) of total soft drinks (hazard ratio [HR], 1.17; 95% CI, 1.11-1.22; P < .001), sugar-sweetened soft drinks (HR, 1.08; 95% CI, 1.01-1.16; P = .004), and artificially sweetened soft drinks (HR, 1.26; 95% CI, 1.16-1.35; P < .001). Positive associations were also observed between artificially sweetened soft drinks and deaths from circulatory diseases (≥2 glasses per day vs <1 glass per month; HR, 1.52; 95% CI, 1.30-1.78; P < .001) and between sugar-sweetened soft drinks and deaths from digestive diseases (≥1 glass per day vs <1 glass per month; HR, 1.59; 95% CI, 1.24-2.05; P < .001).

Conclusions and Relevance  This study found that consumption of total, sugar-sweetened, and artificially sweetened soft drinks was positively associated with all-cause deaths in this large European cohort; the results are supportive of public health campaigns aimed at limiting the consumption of soft drinks.

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    3 Comments for this article
    Confounders and reverse causality?
    J David Spence, M.D. | Robarts Research Institute, London, Canada
    Observational studies of this kind are fraught with hazards of reverse causality and confounders (both measured and unmeasured); they need to be taken with a grain of salt. In this study, people who drank more sweetened soft drinks weighed more, were less educated and smoked more. Aren't obese people more likely to consume sweetened beverages of both kinds? Can adjustment for known confounders really compensate for such differences? Does this study simply mean that obesity is a risk factor?
    CONFLICT OF INTEREST: None Reported
    Unmeasured confounders
    Viviane Lima | University of British Columbia
    The conclusion is quite strong. Based on the analyses, there are several unmeasured confounders that should have been taken into consideration (e.g., comorbid conditions and their severity). Another big limitation is that confounders and exposure were measured at baseline, and the mean follow-up was 16.4 years. Thus, other factors may have played a role in explaining these associations, and the fact that your sample was really large, it is easier to find significant associations. A more robust study would have measured these factors longitudinally, and methods that adjust for time-varying confounders, such as marginal structural models, should have been employed.
    CONFLICT OF INTEREST: None Reported
    Translation to Years of Life Lost ?
    Michael-J McFadden, Bachelor's | Author/Researcher
    Does the data from this study support any possibility at all of making even a rough estimate of years of life lost impact from soda drinking? It would seem that such a figure would have a far stronger resonance with the general public, so it seems a bit strange that no attempt seemed to be made to express this.

    CONFLICT OF INTEREST: Under $200/year for writing in this general area: health habits and their effects.
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