Added Sugar Intake in US Adolescents Linked to Cardiovascular Risk

From Medscape Education Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Hien T. Nghiem, MD



January 31, 2011 — Added sugar intake in US adolescents is linked to increased cardiovascular disease risk, according to the results of a cross-sectional study reported online January 10 in Circulation.

"Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents," write Jean A. Welsh, MPH, RN, from the Nutrition and Health Science Program, Emory University School of Medicine in Atlanta, Georgia, and colleagues.

Dietary data from one 24-hour recall of 2157 US adolescents enrolled in the National Health and Nutrition Examination Survey 1999 to 2004 were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. Measures of cardiovascular disease risk were estimated as a function of added sugar intake level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy). Multivariable means were weighted to be representative of US adolescents, and variances were adjusted to account for the complex sampling methods. Average daily intake of added sugars was 21.4% of total energy. Added sugar consumption correlated inversely with mean high-density lipoprotein (HDL) cholesterol levels (mmol/L). The lowest consumers had a mean HDL of 1.40 (95% confidence interval [CI], 1.36 - 1.44), and the highest consumers had a mean HDL of 1.28 (95% CI, 1.23 - 1.33; P for trend = .001). Added sugar intake correlated positively with geometric mean triglyceride levels (mmol/L), which were 0.81 (95% CI, 0.74 - 0.88) in the lowest consumers and 0.89 (95% CI, 0.83 - 0.96) in the highest consumers (P for trend = .05). Added sugar intake also correlated positively with low-density lipoprotein (LDL) cholesterol levels (mmol/L), which were 2.24 (95% CI, 2.12 - 2.37) in the lowest consumers and 2.44 (95% CI, 2.34 - 2.53) in the highest consumers (P for trend = .01). For adolescents who were overweight or obese, defined as a body mass index at or above the 85th percentile, added sugars correlated positively with the homeostasis model assessment of insulin resistance (HOMA-IR; P for linear trend = .004). "Consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk," the study authors write. Limitations of this study include cross-sectional design with exposures and outcomes measured at the same time, precluding determination of causality; use of a single 24-hour dietary recall; possible residual confounding; and lack of information on the validity of the process used to estimate added sugar content data in the US Department of Agriculture MyPyramid Equivalents databases. "Though long-term trials to study the effect of reducing the consumption of added sugars are needed, the results of this study suggest that future risk of CVD [cardiovascular disease] may be reduced by minimizing consumption of added sugars among adolescents," the study authors conclude. One of the study authors (Miriam B. Vos, MD, MSPH) is supported in part by a career award from the National Institutes of Diabetes and Digestive and Kidney Diseases and by the Children's Digestive Health and Nutrition Foundation. Dr. Vos is also the author of The No-Diet Obesity Solution for Kids, for which he receives royalties. The remaining study authors have disclosed no relevant financial relationships. Circulation. Published online January 10, 2011. Abstract Clinical Context In 1986, the Sugars Task Force of the US Food and Drug Administration concluded that there was no evidence of an association between sugar consumption and cardiovascular disease or its risk factors. Since then, several epidemiologic and experimental studies have demonstrated more evidence linking the intake of carbohydrates and sugars with an increased risk for cardiovascular disease. The Institute of Medicine suggests a limit of 25% total energy from added sugars to ensure adequate intake of important nutrients, the World Health Organization advises limiting added sugars to less than 10% total energy to prevent dental caries, and the American Heart Association advises that daily intake of added sugars be limited to less than 100 calories daily for women and 150 calories for men for the prevention of heart disease. Whereas increased carbohydrate and sugar consumption has been associated with higher cardiovascular disease risk among adults, little is known about the impact of high consumption of added sugars (caloric sweeteners) among US adolescents. The aim of this study was to determine if there is an association between the consumption of added sugars and indicators of cardiovascular disease risk among US adolescents and to determine if body weight modifies this association. Study Highlights * In a cross-sectional study of 2157 US adolescents in the National Health and Nutrition Examination Survey 1999 to 2004, dietary data from one 24-hour recall were merged with added sugar content data from the US Department of Agriculture MyPyramid Equivalents databases. * Exclusion criteria were adolescents with unreliable or implausible (< 600 or > 4500 kcal/day) dietary data, those who were pregnant, those with extreme triglyceride levels (> 300 mg/dL), those with previously diagnosed diabetes mellitus, and those with missing covariate data.
* Measures of cardiovascular disease risk were estimated by added sugar consumption level (< 10%, 10% to < 15%, 15% to < 20%, 20% to < 25%, 25% to < 30%, and ≥ 30% of total energy). * Biological indicators known to be associated with cardiovascular disease were measured, including lipids and glucose metabolism. * HOMA-IR was calculated. This is an estimate of insulin resistance derived from fasting glucose and insulin levels, with higher levels representing greater degrees of insulin resistance. * Multivariable means were weighted to be representative of US adolescents, and variances were adjusted for the complex sampling methods. * No significant differences were observed between the level of added sugars consumed and demographic factors, physical activity, or total energy intake. * Results demonstrated that daily consumption of added sugars averaged 21.4% of total energy. * Added sugar intake correlated inversely with mean HDL cholesterol levels (mmol/L), which were 1.40 (95% CI, 1.36 - 1.44) among the lowest consumers and 1.28 (95% CI, 1.23 - 1.33) among the highest consumers (P for trend = .001). * Added sugars correlated positively with LDL cholesterol levels (P for trend = .01) and geometric mean triglyceride levels (P for trend = .05). * Among the lowest and highest consumers, respectively, LDL cholesterol levels (mmol/L) were 2.24 (95% CI, 2.12 - 2.37) and 2.44 (95% CI, 2.34 - 2.53), and triglyceride levels (mmol/L) were 0.81 (95% CI, 0.74 - 0.88) and 0.89 (95% CI, 0.83 - 0.96). * Among overweight or obese adolescents (> 85th percentile of body mass index), added sugars correlated positively with HOMA-IR (P for linear trend = .004) and higher fasting insulin levels.
* No significant trends were observed between consumption of added sugars and fasting glucose levels, systolic or diastolic blood pressure, waist circumference, or body mass index.

Clinical Implications

* Recently, the American Heart Association released recommendations advising that daily intake of added sugars be limited to less than 100 calories daily for women and 150 calories for men for the prevention of heart disease.
* Higher consumption of added sugars among US adolescents is positively associated with multiple measures known to increase cardiovascular disease risk.

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