Relation of Total Sugars, Sucrose, Fructose, and Added Sugars With the Risk of Cardiovascular Disease: A Systematic Review and Dose-Response Meta-analysis of Prospective Cohort Studies.

Tauseef A Khan, Mobushra Tayyiba, Arnav Agarwal, Sonia Blanco Mejia, Russell J de Souza, Thomas M S Wolever, Lawrence A Leiter, Cyril W C Kendall, David J A Jenkins, John L Sievenpiper

Journal: Mayo Clinic proceedings 2020;94(12):2399-2414

PMID: 31806098

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Plain Language Summary

Sugar-sweetened beverages have been associated with a risk for poor health outcomes, however risk for poor health outcomes with the fructose sugar they contain remains unclear. This systematic review and meta-analysis of 24 prospective cohort studies aimed to determine the role of total added fructose in the development of heart disease. Total sugars, sucrose and fructose were not associated with the incidence of heart disease, however total sugars and fructose increased the risk of death due to heart disease, the extent of which was dependent upon the amount consumed. Interestingly sucrose had a protective effect against death due to heart disease. It was concluded that consumption of fructose, total sugars and added sugars is associated with death due to heart disease, whereas sucrose is not. Although not all food stuffs containing fructose and added sugars were analysed, it is still indicative that healthcare professionals could recommend a low sugar and fructose diet to lower the risk of death due to heart disease.

Abstract

OBJECTIVE

To determine the association of total and added fructose-containing sugars on cardiovascular (CVD) incidence and mortality.

METHODS

MEDLINE, EMBASE and Cochrane Library were searched from January 1, 1980, to July 31, 2018. Prospective cohort studies assessing the association of reported intakes of total, sucrose, fructose and added sugars with CVD incidence and mortality in individuals free from disease at baseline were included. Risk estimates were pooled using the inverse variance method, and dose-response analysis was modeled.

RESULTS

Eligibility criteria were met by 24 prospective cohort comparisons (624,128 unique individuals; 11,856 CVD incidence cases and 12,224 CVD mortality cases). Total sugars, sucrose, and fructose were not associated with CVD incidence. Total sugars (risk ratio, 1.09 [95% confidence interval, 1.02 to 1.17]) and fructose (1.08 [1.01 to 1.15]) showed a harmful association for CVD mortality, there was no association for added sugars and a beneficial association for sucrose (0.94 [0.89 to 0.99]). Dose-response analyses showed a beneficial linear dose-response gradient for sucrose and nonlinear dose-response thresholds for harm for total sugars (133 grams, 26% energy), fructose (58 grams, 11% energy) and added sugars (65 grams, 13% energy) in relation to CVD mortality (P<.05). The certainty of the evidence using GRADE was very low for CVD incidence and low for CVD mortality for all sugar types.

CONCLUSION

Current evidence supports a threshold of harm for intakes of total sugars, added sugars, and fructose at higher exposures and lack of harm for sucrose independent of food form for CVD mortality. Further research of different food sources of sugars is needed to define better the relationship between sugars and CVD. REGISTRATION: clinicaltrials.gov, NCT01608620.

Address: Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Risk Factor Modification Center, St. Michael's Hospital, Toronto, Ontario, Canada.; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Risk Factor Modification Center, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Risk Factor Modification Center, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, Ontario, Canada.; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Risk Factor Modification Center, St. Michael's Hospital, Toronto, Ontario, Canada; College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.; Department of Nutritional Sciences, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Risk Factor Modification Center, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, St. Michael's Hospital, Toronto, Ontario, Canada. Electronic address: [email protected].

DOI: 10.1016/j.mayocp.2019.05.034