Soda and Heart Disease

Sweetened Beverage Consumption, Incident Coronary Heart Disease and Biomarkers of Risk in Men

Koning,L. Malik, V., Kellogg, M., Rimm, E., Willett, W.,  Hu, F. Circulation. 2012

The above named scientists reviewed two very big longitudinal studies.  The people involved in the studies were men (health care professionals) and women (nurses).  The people joined the study several decades ago.  They answered questions about their health and diet and had lab work completed.  As the years passed, they continued to give information on their diet and lifestyle, diseases that they contracted (confirmed by records) and more blood samples at certain times.  This is the kind of study that is helpful in establishing links between what people do - or what they are exposed to - and disease occurrence. 

A person is interviewed and measured (weight, blood pressure, insulin test, etc) at the start.  This is their baseline.  They do not have any indication of heart disease or lung problems (if they do, they are not included in the study, for instance).  Every year or so they tell about their diet and behavior and when a disease does present itself, the scientists can associate that disease with something that happened in between.  This is not a randomized controlled experiment - which is the only kind of study that can really show cause.  It is however, a very good study and when you have thousands of people instead of ten or twenty the links from lifestyle to disease appear much stronger.  Even then, the link is found in a big sample of people and applies to big samples of people - it is not individual risk.

In this study, the scientists found that sugar sweetened beverages, (soda, juices and such, but mostly soda) were associated a higher risk of heart disease.  The important part is that they know why..  Just as being overweight doesn't cause heart disease directly, drinking soda doesn't lead straight to a heart attack.  If scientists can find the in between factor, the mechanics, and they make biological sense -it contributes to the "evidence".  

Here they found that the SSB consumption did change biomarkers or under the skin conditions that are themselves associated with heart disease.  People who drank several sodas a day compared to those who drank none, had higher triglycerides, lower HDL, more inflammation (CRP, inter luekin 6, TNf) and their leptin (appetite suppression) hormone was less effective.  The researchers expect that process is being triggered by the fructose.  Those who drank the most soda had about 20% higher risk of heart disease. 

The people in the study, again, were health care professionals.  They did not drink that much soda to begin with and may not be representative of the larger US population.  However, there is every reason to believe that drinking a lot of soda is not good for people. (it is important to note that in data analysis, there are procedures that allow us to pretend that everyone was the same weight and ate the same way - so that the impact on these biomarkers could be attributed to the soda and not some other part of the persons life)

The best part of the article is this statement - for my personal reasons: From p 14 in the above referenced study - 

Our results highlight the need for cautious interpretation of studies reporting positive associations between diet drinks and cardiometabolic and cardiovascular outcomes.

What that means is that they do not at this time support the hypothesis or suggestion that diet drinks cause the same problems as regular soda.  Yeah me! (cardiometabolic - think heart - so blood pressure, cholesterol, blood fats, inflammation - and metabolic - digestion and enzymes - insulin resistance, appetite control)

Degree Not Needed, Sugar Pooh

I purposefully left my Monday blog up for two days.  I felt that the issue was important enough for us to dwell on.  Yesterday the Diane Rehm show discussed diabetes and its association with weight, the importance of choosing better foods and the benefit of adding exercise to every day.  A caller to the show talked about his diagnosis of diabetes and how hard it was to eat well outside of his own home.  He had gone to an event to support one of his children and  he recalled the breakfast they served; toast, hashbrowns, bacon, eggs, and so on .  He said it was as if the culture we live in was set up to create a diabetes epidemic.  Some public health experts would agree.  Diane added some comments about how hard it was to find anything of quality to eat when traveling by plane.  I think that is changing a little, but you really have to know what you are doing in order to make healthy choices.  I linked her show in case you want to listen.  She had several experts on as guests.

I had to mention the show because it was important, but my post today really centers on something that I observed in one of my classes last night.  The student sitting next to me had a canned drink that at first appeared to be an energy drink because of its size.  I think it was just a smaller can of coca cola.  I could see the back and the label.  I noticed that it had 25 grams of sugar and 90 calories.  I thought, well, if she would have had a 150 to 200 calorie drink, that is better.  At class break, she came back with a pack of nabs and a 12 ounce bottle of regular Dr. Pepper.  Meanwhile, I had a diet Mt Dew and half a peanut butter sandwich.  My classmate weighs significantly more than me, possibly 100 pounds more.  
On the one hand, we could say, "Well this isn't rocket science then.  One of us was monitoring or moderating our intake and the other was not."  Of course, what an observer doesn't know and I don't know, is what goes into the decisions people make.  Food decisions tend to be much more nuanced than they appear to be.  I would, however, like to show people how they can eat and drink more without taking in extra calories (extra meaning more than they need to maintain a healthy weight). 

But especially after the last post on sugar sweetened beverages, I found last nights observation troubling.

SSBs - HD, TG, WC, IFG and that is not what the headline said......

The American Heart Association held a conference in Orlando Florida over the weekend.  Many sessions were held during the event and new research was presented during some of them.  The conference topics were broken into large core groups and one of them, Epidemiology and Prevention of CV Disease: Physiology, Pharmacology and Lifestyle contained several presentations regarding sugar sweetened beverages and added sugar. A particular session titled, You Are (mainly)What You Eat, regarded a new (not yet published) study,  by Christina Shay.  Dr. Shay is from Northwestern University.   The findings that she reported at the conference have been making headlines all over the place in the last two days.  I have read the abstract and you can too, as well as some of the news stories themselves.  

There is a little bit of a disconnect between the two and as I LOVE to share truth - I will do so now.

I will start by deciphering my title.  SSBs you should know from reading my blog.  It stands for Sugar Sweetened Beverages.  For the study in question, the researchers compared the number of sugar sweetened beverages a person consumed in an average day to cardiovascular risk factors they later developed.  I will spell those out in a moment.  The amount of SSBs was determined through self report in a Food Frequency Questionnaire.  A sugar sweetened beverage was defined as sodas, teas and coffees - a health professional interviewed by one of the news agencies referred to the coffee drink as a dessert more than a beverage.  (I am not sure what they did about fruit, energy and sports drinks)  

The people involved in the study were part of a bigger study but we won't get into that just now.  For this analysis, the study included men and women of several ethnic backgrounds (US).  All were  between the ages of 45 and 84 at the beginning of the study which lasted from 2002 to 2007.  

At the start (or baseline), none of the participants had been diagnosed with heart disease (HD).  They were evaluated or measured at two additional times.  Associations between a person's intake of certain nutrients was compared with incidence of several outcomes.  (I imagine that SSB was not the only thing they looked into, but it is the only behavior they made associations with in this report).
The outcomes for which they found a statistically significant difference between groups include WC or waist circumference, IFG or impaired fasting glucose (a sign of insulin resistance and possible risk for diabetes), and TG or triglycerides (blood fats).  
They compared groups by SSB status.  The group that they considered a reference included persons who had one or less SSB per day.  Compared to that reference group, women in the study who drank 2 or more SSB a day, had more of an increase in waist size (WC), IFG and TG.  One of the results that is getting a lot of attention is that the 2+ a day SSB group was 4 times more likely to have clinically high TG.  Triglycerides are blood fats and it appears that excess sugar in the diet can lead to increased TGs.
I am not sure what the news stories were trying to articulate, but the emphasis they made was on increasing TG levels related to sugary beverage consumption, "even in skinny girls."  This may be related to the finding in the actual study or the truth that the 2+ group had increased waist size whether or not they had increased weight.  Increased WC is the risk factor for heart disease not increased weight - so the headline is misleading. 

It is also worth reminding people that sugar consumption is one of the main contributors to obesity because it is easy to consume more calories than you need or even realize your consuming with sugar products.
It is also important to note that refined sugar, in drinks or sweets, spikes the blood sugar.  Having this type of action in the body several times a day every day is a great risk for insulin resistance.  Diabetes is a cardiovascular (heart) problem.  We do not often think of it that way, but the condition leads to heart damage.  
The soft drink case is especially pronounced in women. 

SSB in the news again

More than one person has alerted me to the report on sugar sweetened beverage (SSB) consumption that was released this week.  It has been reported in and on the news.  If I did not mention it here, my readers might wonder what had happened to me.  So I took a moment to gather a few things together for sharing.  Please understand that this information is from self report - not observations (meaning that the consumption is likely to be higher not lower.  The information is also least three years old.  It would be interesting to see if these numbers change as more states work on limiting these beverages through vending machine exclusion and taxes.

This information comes from a recent review of NHANES data undertaken by researchers from the National Center for Health Statistics and the CDC.  The authors of this particular report and its citation are as follows: 
Ogden CL, Kit BK, Carroll MD, Park S. Consumption of sugar drinks in the United States, 2005–2008. NCHS data brief, no 71. Hyattsville, MD: National Center for Health Statistics. 2011.
The key findings, copied from the web page, are below.  I strongly encourage you to click on this link to see the full BRIEF.  It is not hard to understand and it is illuminating.  The information is a generalization and it includes population averages.  In these averages it would seem that almost everyone drinks at least one sugar sweetened beverage a day (actually it is half of all Americans), most drink more than that and poorer people drink more still.  There is also a difference between races - you can unpack that one yourself, most people know what I think about that.  I myself drink NO SSB a day and one of my sisters drinks 4 or so - guess we cancel each other out statistically speaking.  My other sister is closer to me on the SSB issue - same with our Mom.

Data from the National Health and Nutrition Examination Survey, 2005–2008

• Males consume more sugar drinks than females.
• Teenagers and young adults consume more sugar drinks than other age groups.
• Approximately one-half of the U.S. population consumes sugar drinks on any given day.
• Non-Hispanic black children and adolescents consume more sugar drinks in relation to their overall diet than their Mexican-American counterparts. Non-Hispanic black and Mexican-American adults consume more than non-Hispanic white adults.
• Low-income persons consume more sugar drinks in relation to their overall diet than those with higher income.
• Most of the sugar drinks consumed away from home are obtained from stores and not restaurants or schools.

This is one of many interesting charts that are including in the full brief.

If you can't tax it - ban it

I am thrilled to attach the current newsletter from the Harvard School of Public Health.  It announces a policy change for the city of Boston. 
All new beverage contracts, for city owned properties, will include only low calorie beverages and NO SODA or sugar sweetened beverages (SSB)i.e sports drinks .  Diet soda will be allowed, but there is a limit on the proportion of diet soda to non diet drinks per total vending machine, or canteen menu.  If you click on one of the side links, you will see the report on diet drinks. In short, they are not considered the best alternative, but perhaps a step down from full sugar to no sugar beverages.  In that article,  some research is cited that indicates that having the sweetness without the calories confuses the brain.  The signals for satiety do not get sent and people over consume.  I drink a diet soda every day with a small snack and I am the least overweight person I know.  [this may be related to the fact that I am not drinking the soda to trick myself into thinking that I ate, but because I enjoy the taste. Also, I am consuming a low calorie snack at the same time - so I feel full AND have calories]

 Another research example they gave involved rats.  I am just thinking - rat studies - for calorie consumption - do not make a lot of sense because rats do not eat for all the reasons that people eat.  Much of our eating has to do with social pressure, happiness, sadness, etc - where as, I assume rats eat because they are hungry.

So back to the BAN.  Boston is also going to utilize my favorite Go Slow Whoa labeling  - Green means go -  water would be green, fruit juice (100% and small serving) would be yellow, and soda or whole milk would be red.  OK truth is that I did not open their traffic light guide, but I think I know this stuff well enough to guess correctly.  But that reminds me, though they will allow fruit juice, the serving size cannot be more than 8 ounces.  They are allowing low fat/no fat milk too - but again, in limited sizes.

I am so excited about this initiative that I emailed one of my professors to see how I could make something like this happen on my campus :)  I told him I would dedicate my summer to it.  I will keep you posted.

I also emailed it to the obesity coalition of which I am a part - perhaps we could influence my city :)

You are more than welcome to pass it on yourselves.  Here it is.  (I still think taxing or price differentials are good strategies too)  In this article, my hero, Walter Willett (MD) equates soda consumption with the greatest single cause of our obesity epidemic.  It was said that many people consume 200 calories a day in soda or SSB - well the average person.  That is only about one soda a day - I know many who drink several cans/bottles a day.