Effect of sugar intake on cardiovascular health

Cardiovascular disease (CVD)

• 'A higher than recommended intake of added sugars among adolescents may be positively associated with multiple measures known to increase cardiovascular disease risk'.
• 'Data in adolescents reflect interventional studies in adults suggesting that higher fructose consumption (from added sugars) is also associated with multiple factors that increase risk for cardiovascular disease…'.

NNR 2023

• SSBs are associated with increased risk of cardiovascular disease. 

DGAC 2020

• ‘Limited evidence from prospective cohort studies that were based primarily on sugar-sweetened beverages suggests that higher consumption of added sugars in adulthood is associated with increased risk of cardiovascular disease mortality.‘ 

Coronary Heart Disease

  SACN 2015 (pdf)  

• Based on moderate evidence, no significant association observed between sugars consumption and coronary event incidence.

• Added sugars have consistently been associated with elevated risk of coronary heart disease.

Blood pressure

• Evidence (very low level of certainty) for causal relationship between intake of added/free sugars and risk of hypertension

• SSBs are associated with increased risk of hypertension.

• 'Concerning […] blood pressure, in the short- and medium-term intervention studies, deleterious metabolic effects of sugars were observed, in the case of very high consumption and/or consumption associated with an excess energy intake. However, the long-term impact of these changes on the occurrence of pathologies remains unknown'.

• 'There is possible evidence that there is no association between long-term intake of fructose or sucrose and blood pressure increase'.
• 'There is possible evidence that there is no association between the intake of sugar-sweetened beverages and the risk of hypertension. This judgement is based on 1 cohort study only, but is confirmed by the judgement of the individual components of sweetened beverages like fructose and sucrose'.

• Based on limited evidence, no significant effect is demonstrated for diets differing in the proportion of sugars on systolic blood pressure or diastolic blood pressure.

Blood lipids

• Evidence (moderate level of certainty) for causal relationship between intake of added/free sugars and risk of dyslipidaemia

• High intake of added and free sugars is associated with risk of dys­lipidaemia

• 'epidemiological studies indicate a hypertriglyceridemia effect of sugars provided in the form of sugar-sweetened beverages, but these data do not show a specific effect, independent of total energy intake'.
• 'The effect of sugars containing fructose (sucrose, HFCS), the respective roles of excess energy or sugar intake per se, and the effect of co-ingestion of glucose and fructose, are still poorly understood. But in the intervention studies, daily intakes of fructose above 50 g/d can lead to an increase in fasting and/or post-prandial blood triglycerides'.

• 'the evidence is judged as probable that there is no association between a fructose intake of < 100 g/day and the fasting plasma triglyceride concentration as well as between a fructose intake of < 50 g/day and the postprandial plasma triglyceride concentration, respectively'.
• 'There is convincing evidence that with higher fructose intake of up to 350 g/day, the fasting plasma triglyceride concentration increases'.

• Based on limited evidence, no significant effect is demonstrated for diets differing in the proportion of sugars on fasting total cholesterol, fasting low density lipoprotein (LDL) or high density lipoprotein (HDL) cholesterol concentration, or fasting triacylglycerol concentration.

Effect of sugar intake on type 2 diabetes mellitus (T2DM) and blood glucose

• Evidence (low level of certainty) for causal relationship between intake of added/free sugars and risk of type 2 diabetes

• SSBs are associated with increase risk of type 2 diabetes

• 'Concerning glucose homeostasis and insulin sensitivity, the studies indicate that only a very large increase in fructose intake, of around 80 g/d, leads to a decrease in hepatic sensitivity to insulin. This effect, however, is modest and is not accompanied by a clinically significant increase in fasting blood glucose'.
• 'A limited number of epidemiological cohort studies indicate an increase in the incidence of diabetes in high consumers of sugar-sweetened beverages; however this is in part linked to the weight status'.
• For those pathologies where weight gain and obesity are established risk factors, in particular for T2DM, the contribution of sugars to excess energy intake must not be overlooked.

• 'the evidence regarding a lack of an association between sucrose intake and the risk of type 2 diabetes mellitus is judged as probable'.
• 'the evidence regarding a lack of an association between lactose intake and the risk of diabetes is judged as possible'.
• Majority of studies indicate 'an increased risk of type 2 diabetes mellitus due to regular consumption of sugar-sweetened beverages. The evidence regarding this association is judged as probable'.

• Based on limited evidence, there is no effect of sugars consumption on fasting blood glucose concentration and blood insulin concentrations.
• Based on limited evidence, there is 'no consistent evidence of an association between diets differing in the proportion of sugars in relation to incidence of type 2 diabetes mellitus'. Sucrose and fructose were also individually examined with same findings.
• Based on moderate evidence, an association was found between greater sugars-sweetened beverage (SSB) soft-drink consumption and higher incidence of type 2 diabetes mellitus, while there was insufficient evidence that included fruit juices. The association direction indicates that 'greater consumption of SSBs is detrimental to health'.

• 'Added sugars have consistently been associated with elevated risk of type 2 diabetes...'

• 'Strong evidence shows that higher consumption of added sugars, especially sugar-sweetened beverages, increases the risk of type 2 diabetes among adults and this relationship is not fully explained by body weight'.

• For those pathologies where weight gain and obesity are established risk factors, in particular for endometrial cancer and breast cancer, the contribution of sugars to excess energy intake must not be overlooked.

• 'There is possible evidence of a positive association between the intake of monosaccharides and malignant tumours of the pancreas'
• 'There is possible evidence of a lack of a risk relation between the intake of disaccharides and the development of malignant tumours in the colorectum, breast and pancreas'
• 'There is also possible evidence regarding a lack of an association between the intake of sugar-sweetened beverages and cancer of the colorectum and pancreas'.

• Based on adequate evidence, no association was found between consumption of SSBs and colon cancer incidence.

• Evidence (moderate level of certainty) for causal relationship between intake of added/free sugars and risk of obesity

• High intake of added and free sugars is associated with risk of obesity.
• SSBs are associated with increased risk of obesity. ‘Replacing sugar-sweetened beverages with low- or no-calorie-sweetened beverages may result in a small reduction in body weight.’

• 'A higher than recommended intake of free sugars, particularly SSBs in children and adolescents, is associated with increased incidence of […] adiposity'.
• 'Sugars-containing beverages do not promote satiety compared the equivalent amount of sugars in solid form and therefore induce excessive energy intakes'.
• 'Reducing the intake of SSBs by replacing them with water in children and adolescents is associated with reduced weight and adiposity'.

• 'Weight gain is related to an excess energy intake. Sugars and particularly sugar-sweetened beverages contribute to this excess energy intake'.
• 'sugars, and more particularly in liquid form (sodas, nectars, fruit juices produced from concentrates, fresh fruit juices, smoothies, etc.) contribute to weight gain, with a convincing level of evidence'.

• 'The available cohort and intervention studies regarding adults mainly show that a higher consumption of sugar-sweetened beverages is accompanied by an increased risk of obesity. Therefore, the respective evidence is judged as probable'.
• 'The overall evidence regarding an increased risk of obesity due to higher consumption of sugar-sweetened beverages in children and adolescents is […] only judged as possible'.
• 'The evidence regarding an increased risk of obesity especially in children and adolescents with initially already increased BMI or already existing overweight is also judged as possible'.

• Based on adequate evidence, sugars consumption has an effect on energy intake; the direction of the effect demonstrates that greater consumption of sugars is detrimental to health (relevant in free living individuals not subject to energy restriction).
• In randomised control trials (RCTs), and based on limited evidence, SSBs consumption has an effect on BMI; 'the direction of the effect demonstrates that greater consumption of SSBs is detrimental to health.'

• Added sugars have consistently been associated with elevated risk of excess body weight.
   

• ‘Moderate evidence suggests that higher sugar-sweetened beverage intake is associated with greater adiposity in children.’
• ‘Limited evidence suggests that higher sugar-sweetened beverage intake is associated with greater adiposity in adults.’
• ‘Limited evidence suggests no association between sugar-sweetened beverages compared with low- and no- calorie sweetened beverages on adiposity in adults.’

EFSA 2022a

• 'The intake of dietary sugars is a well-established hazard in relation to dental caries in humans.’

• Moderate quality evidence from cohort studies suggests a positive association between levels of free sugars intake and dental caries; higher rates of caries when free sugars intake exceeds 10% of total energy. In three population studies with very low quality of evidence, lower levels of caries development were observed with approx. free sugars intake of 5%.

• 'A higher than recommended intake of free sugars, particularly SSBs in children and adolescents, is associated with increased incidence of dental caries…'.

NNR 2023

• High intake of added and free sugars is associated with dental caries.

• Based on moderate evidence, there is an association between amount of sugars consumed and dental caries in mixed and permanent dentition; 'The direction of the association indicates that greater consumption of sugars is detrimental to oral health'. No significant association reported between the frequency of sugars consumption and the risk of developing dental caries in mixed and permanent dentition.
• Adequate evidence for an association between the amount and frequency of SSBs and detriment to deciduous dentition. 'The direction of the association indicates that greater consumption of sugars sweetened beverages is detrimental to oral health'.
• Amount and frequency of consumption of sugar containing foods and/or confectionary is associated with dental caries. 'The direction of the association indicates that greater consumption of sugars containing foods and/or sugars confectionery is detrimental to oral health'. For deciduous dentition there is limited evidence, while for mixed and permanent dentition the evidence is moderate.

• 'The DGAC concurs with the World Health Organization's commissioned systematic review that moderate consistent evidence supports a relationship between the amount of free sugars intake and the development of dental caries among children and adults. Moderate evidence also indicates that caries are lower when free sugars intake is less than 10 percent of energy intake'.

• ’Observed negative associations between added sugars intake and micronutrient density of the diet are mainly related to patterns of intake of the foods from which added sugars in the diet are derived rather than to the intake of added sugars per se.’

• ‘Increasing intake of added and free sugars leaves less room for healthy foods and micronutrients, which is especially important for those with low energy intake, such as children’

• 'The evidence regarding an association between the consumption of sugar-sweetened beverages and the occurrence of the metabolic syndrome is judged as possible'.

EFSA 2022a

• Evidence (low level of certainty) for causal relationship between intake of added/free sugars and risk of non-alcoholic fatty liver disease

• 'Observational studies, show that SSB intake during infancy and early childhood is associated with SSB intake in childhood and adolescence', but cannot demonstrate causality.

• 'the introduction of added sugars during infancy appears to be particularly harmful and should be avoided'.