Added Sugar Intake and Cardiovascular Diseases Mortality Among US Adults

Study Questions:

Is higher intake of added sugar associated with cardiovascular (CV) mortality?


Data from the National Health and Nutrition Examination Survey (NHANES, 1988-1994 [III], 1999-2004, and 2005-2010), which included 31,147 adults, were used for this analysis. Included in this were data from the NHANES III Linked Mortality cohort (1988-2006 [n = 11,733]), a prospective cohort of a nationally representative sample of US adults. Estimates of added sugar intake were obtained from 24-hour dietary recalls. Added sugars included all sugars used in processed or prepared foods, such as sugar-sweetened beverages, grain-based desserts, fruit drinks, dairy desserts, candy, ready-to-eat cereals, and yeast breads, but not naturally occurring sugar, such as in fruits and fruit juices. The primary outcome of interest was CV disease (CVD) mortality.


The adjusted mean percentage of daily calories from added sugar increased from 15.7% (95% confidence interval [CI], 15.0%-16.4%) in 1988-1994 to 16.8% (16.0%-17.7%; p = 0.02) in 1999-2004, and decreased to 14.9% (14.2%-15.5%; p < 0.001) in 2005-2010. Most adults consumed ≥10% of calories from added sugar (71.4%), and approximately 10% consumed ≥25% in 2005-2010. During a median follow-up period of 14.6 years, a total of 831 documented CVD deaths occurred during 163,039 person-years. After adjustment for multiple potential confounders (age, sex, race/ethnicity, sociodemographic, behavioral, and clinical characteristics), hazard ratios (HRs) for CVD mortality across the quintiles of the percentage of daily calories consumed from added sugar were 1.00 (reference), 1.07 (1.02-1.12), 1.18 (1.06-1.31), 1.38 (1.11-1.70), and 2.03 (1.26-3.27; p = 0.004), respectively. Adjusted HRs were 1.30 (95% CI, 1.09-1.55) and 2.75 (1.40-5.42; p = 0.004), respectively, comparing participants who consumed 10.0% to 24.9% or ≥25.0% calories from added sugar with those who consumed <10.0% of calories from added sugar. These findings were largely consistent across age group, sex, race/ethnicity (except among non-Hispanic blacks), educational attainment, physical activity, health eating index, and body mass index.


The investigators concluded that a significant relationship between added sugar consumption and increased risk for CVD mortality exists.


A significant number of Americans consume added sugar at levels associated with increased risk of CVD mortality based on this study. Therefore, advising patients to limit their intake of added sugar should be part of clinical advice for a healthy lifestyle to limit risk of CV events. Further research is warranted to determine if reducing added sugar would result in reductions in CVD risk.

Clinical Topics: Prevention, Diet

Keywords: Candy, Carbohydrates, Fruit, Bread, Sweetening Agents, Cardiovascular Diseases, Cereals, Beverages, Energy Intake, Nutrition Surveys, Dietary Sucrose

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