Sugar-Sweetened Beverage Consumption and Incident Cardiovascular Risk Factors:

The Multi-Ethnic Study of Atherosclerosis(MESA)

Christina Shay PhD MA1 Jennifer Nettleton PhD2; Pamela Lutsey PhD MPH3;

Tamar Polonsky MD4; Mercedes Carnethon PhD4; Linda Van Horn PhD RD4,

Gregory Burke MD MSc5

1Dept of Biostatistics and Epidemiology, Univ of Oklahoma Health Sciences Ctr, Oklahoma City, OK ; 2Div of Epidemiology, Human Genetics and Environmental Sciences, Univ of Texas School of Public Health, Houston, TX; 3Div of Epidemiology and Community Health, Univ of Minnesota, School of Public Health, Minneapolis 4Dept of Preventive Medicine, Feinberg School

of Medicine, Northwestern Univ, Chicago, IL; 5Div of Public Health Sciences, Wake Forest Univ Health Science, Winston-Salem, NC

Corresponding Author: christina-shay@ouhsc.edu

Background

• Sugar-sweetened beverage (SSB) consumption has been associated with weight gain and obesity, dyslipidemia, hyperglycemia, type 2 diabetes, and increased risk for cardiovascular (CV) events

• The association between SSB consumption and development of CV risk factors has not been extensively examined in large, prospective, multi-ethnic cohorts

Objective

• To quantify the association between SSB consumption and risk for developing individual CV risk factors in men and women in the Multi-Ethnic Study of Atherosclerosis (MESA)

MESA Study Description6,814 participants recruited in 2000-2002

Field Centers:- Baltimore - New York

- Chicago - St. Paul

- Los Angeles - Winston-Salem

• 45-84 years, free of clinical cardiovascular disease

• 57% women • 38% Non-Hispanic White, 28% African-American,

22% Hispanic, 12% Chinese American

Assessment of SSB Intake

• Food Frequency Questionnaire (FFQ) was used to measure SSB consumption at the first exam (2000-2002)

• The FFQ specifically asked about consumption of “regular soft drinks, soda, sweetened mineral water (not diet), and nonalcoholic beer”

• SSB intake was categorized into the following groups: 0-<1, 1-<2, and 2+ servings per day

CV Risk Factors Definitions (1)

• Weight Gain: Weight on any follow-up exam or average of all exam weight measurements >3% higher than baseline

• Increased Waist Circumference (WC): WC from any follow-up exam or average of all exam WC measurements >3% higher than baseline

• High Triglycerides: HDL >40 mg/dL (men), > 50mg/dL (women), LDL <160mg/dL, and triglycerides >150mg/dL

• Low HDL cholesterol: HDL <40mg/dL (men), <50 mg/dL (women), LDL <160mg/dL, and triglycerides <150mg/dL

• Impaired Fasting Glucose: Fasting plasma glucose 100-125 mg/dL

• Type 2 Diabetes (T2D): Fasting glucose ≥126 mg/dL, medication use for T2D or self-reported T2D

CV Risk Factors Definitions (2)

Selection of Study Participants for the Current Study

8

6,814 MESA participants ages 45-84 and free of clinical CVD at first exam

General Analysis Sample (n=4,166)

Lipid Analyses (n=1,614)

IGT Analyses (n=3,437)

Excluded Participants

No follow up exams (n=761)

Type 2 diabetes at baseline(n=773)

BMI <18.5 kg/m2 at baseline (n=37)

Missing covariates of interest (n=1,077)

Additional Exclusions

Lipid Medication Use (n=2,552)

Impaired fasting glucose at baseline (n=729)

Statistical Analyses• Cox proportional hazards regression used

estimate hazard ratios

• All risk estimates adjusted for:

• Age

• Sex

• Race/ethnicity

• Study center

• Educational attainment

• Intentional exercise

• Smoking status

• Dietary intake (i.e., total energy, fiber, saturated fat, cholesterol, fruits and vegetables, sodium)

• Family history of T2D (for T2D

incidence)

• Time-varying BMI and WC

Results

Table 1: MESA Baseline Characteristics According to SSB Consumption

Sugar-sweetened beverage consumption (s/day)

0 - <1 1 - <2 2+

Number of Participants 3418 490 258

Male sex (%)** 44.5 56.1 54.6

Age (years)** 61.7 (10.3) 58.8 (9.8) 56.2 (8.9)

Current smokers (%)** 11.3 17.8 19.0

Body Mass Index (kg/m2)** 27.5 (5.0) 29.3 (5.3) 30.0 (6.1)

Waist Circumference (cm)** 95.6 (13.6) 100.2 (13.2) 101.1 (14.9)

Total Intentional Exercise, MET-min/wk [median (IQR)]**

945.0 (210.0 - 2175.0)

630.0 (0.0 -1635.0) 495.0 (0.0 - 1680.0)

HDL Cholesterol (mg/dL)** 52.7 (15.5) 48.8 (13.9) 46.9 (12.9)

LDL Cholesterol (mg/dL) 120.0 (30.8) 119.4 (31.1) 122.1 (30.0)

Triglycerides [median (IQR)]* 106.0 (75.0-153.0) 108.0 (79.0-153.0) 113.0 (81.0-167.0)

Fasting Plasma Glucose (mg/dL)

88.8 (10.4) 89.6 (10.3) 90.1 (10.3)

Systolic Blood Pressure (mmHg) 124.6 (21.0) 124.7 (20.7) 123.1 (19.5)

Diastolic Blood Pressure (mmHg)** 71.5 (10.2) 73.4 (10.9) 73.6 (9.9)

Follow-Up Time, years 4.7 (0.8) 4.7 (0.8) 4.6 (0.8)IQR, interquartile range; Significantly different across groups, *p-value < 0.01, **p-value < 0.001

Hazard Ratios (95% CI) for Weight Gain According to Level of Sugar-Sweetened Beverage Consumption:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Series10

1

2

3

4

5

6

7

8

9

0-<1 1-<2 2+

Servings/Day

Men Women

Haz

ard

Rat

ios

(95%

C.I

.)

Series10

1

2

3

4

5

6

7

8

9

0-<1 1-<2 2+

Servings/Day

Hazard Ratios (95% CI) for Increased Waist Circumference According to Level of Sugar-Sweetened Beverage Consumption:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Men Women

Haz

ard

Rat

ios

(95%

C.I

.)

Series10

1

2

3

4

5

6

7

8

9

0-<1 1-<2 2+

Servings/Day

Hazard Ratios (95% CI)* for High Triglycerides According to Level of Sugar-Sweetened Beverage Consumption:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Men Women

Haz

ard

Rat

ios

(95%

C.I

.)

Series10

1

2

3

4

5

6

7

8

9

0-<1 1-<2 2+

Servings/Day

Hazard Ratios (95% CI) for Low HDL Cholesterol According to Level of Sugar-Sweetened Beverage Consumption:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Men Women

Haz

ard

Rat

ios

(95%

C.I

.)

Series10

1

2

3

4

5

6

7

8

9

0-<1 1-<2 2+

Servings/Day

Hazard Ratios (95% CI) for Impaired Fasting Glucose According to Level of Sugar-Sweetened Beverage Consumption:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Men Women

Haz

ard

Rat

ios

(95%

C.I

.)

Series10

1

2

3

4

5

6

7

8

9

0-<1 1-<2 2+

Servings/Day

Hazard Ratios (95% CI) for Type 2 Diabetes According to Level of Sugar-Sweetened Beverage Consumption:

The Multi-Ethnic Study of Atherosclerosis (MESA)

Men Women

Haz

ard

Rat

ios

Summary• Women who consumed 2+ SSBs per day

exhibited higher risk for developing:

– high triglycerides

– impaired glucose tolerance

– increased waist circumference

compared to women who consumed <1 SSB per day

• These associations remained even after accounting for baseline and time varying BMI and WC

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Strengths and LimitationsStrengths• The MESA study is a large, population-based

cohort designed to examine the development of

CVD risk factorsLimitations• Food frequency item used likely to not have

captured all types of SSBs consumed

American Beverage Association

"This type of study cannot show that drinking sugar-sweetened beverages

causes increased risk for cardiovascular disease. It simply looks at associations

between the two, which could be the result of numerous other confounding factors.”

Conclusions

• The influence of SSBs consumption on cardiovascular risk is complex and may not be the same between middle- and older-aged men and women

• Women exhibit lower energy requirements compared to men and may therefore experience higher CV risk when a greater proportion of calories is consumed in the form of SSBs

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Acknowledgements

• Co-Authors: Jennifer Nettleton, Pamela Lutsey, Tamar Polonsky, Linda Van Horn, Gregory Burke

• MESA’s Funding Agency:

National, Heart, Lung, and Blood Institute (NHLBI)

THANK YOU

Table 1: Characteristics According to SSB Consumption at First Exam

Sugar-sweetened beverage consumption (s/day)

0 - <1 1 - <2 2+

Number of Participants 3418 490 258

Sugar-sweetened beverage consumption (s/day) [median]**

0.0 1.0 2.5

Male sex (%)** 44.5 56.1 54.6

Age (years)** 61.7 (10.3) 58.8 (9.8) 56.2 (8.9)

Education > high school (%) 68.0 65.1 63.6

Current smokers (%)** 11.3 17.8 19.0

Body Mass Index (kg/m2)** 27.5 (5.0) 29.3 (5.3) 30.0 (6.1)

Waist Circumference (cm)** 95.6 (13.6) 100.2 (13.2) 101.1 (14.9)

Total Intentional Exercise, MET-min/wk [median (IQR)]*

945.0 (210.0 - 2175.0) 630.0 (0.0 -1635.0) 495.0 (0.0 - 1680.0)

HDL Cholesterol (mg/dL)** 52.7 (15.5) 48.8 (13.9) 46.9 (12.9)

LDL Cholesterol (mg/dL) 120.0 (30.8) 119.4 (31.1) 122.1 (30.0)

Triglycerides [median (IQR)]* 106.0 (75.0-153.0) 108.0 (79.0-153.0) 113.0 (81.0-167.0)

Fasting Plasma Glucose (mg/dL) 88.8 (10.4) 89.6 (10.3) 90.1 (10.3)

Systolic Blood Pressure (mmHg) 124.6 (21.0) 124.7 (20.7) 123.1 (19.5)

Diastolic Blood Pressure (mmHg)** 71.5 (10.2) 73.4 (10.9) 73.6 (9.9)

Anti-Hypertensive Medication use (%) 29.9 28.8 29.1

Follow-Up Time, years 4.7 (0.8) 4.7 (0.8) 4.6 (0.8)IQR, interquartile range; Significantly different across groups, *p-value < 0.01, **p-value < 0.001

CV Risk Factors

Sugar-Sweetened Beverage Consumption

Women Men

0 - <1 1 - <2 2+ 0 - <1 1 - <2 2+Weight gain >3%              N 1759 195 102 1412 253 129  # Cases 694 89 47 508 78 51WC gain >3%              N 1759 195 102 1412 253 129  # Cases 953 108 65 586 94 57Hypertriglyceridemia1          

  N 790 83 37 576 81 47  # Cases 79 11 9 79 10 5Low HDL1              N 790 83 37 576 81 47  # Cases 116 19 6 73 13 10Type 2 diabetes              N 1897 215 117 1521 275 141  # Cases 138 20 15 109 22 12Impaired Fasting Glucose  N 1621 179 93 1215 217 112  # Cases 331 39 25 324 51 24

Sample Sizes