Association Between Soft Drink Consumption and Mortality in 10 European Countries

Abstract

Importance: Soft drinks are frequently consumed, but whether this consumption is associated with mortality risk is unknown and has been understudied in European populations to date.

Objective: To examine the association between total, sugar-sweetened, and artificially sweetened soft drink consumption and subsequent total and cause-specific mortality.

Design, setting, and participants: This population-based cohort study involved participants (n = 451 743 of the full cohort) in the European Prospective Investigation into Cancer and Nutrition (EPIC), an ongoing, large multinational cohort of people from 10 European countries (Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain, Sweden, and the United Kingdom), with participants recruited between January 1, 1992, and December 31, 2000. Excluded participants were those who reported cancer, heart disease, stroke, or diabetes at baseline; those with implausible dietary intake data; and those with missing soft drink consumption or follow-up information. Data analyses were performed from February 1, 2018, to October 1, 2018.

Exposure: Consumption of total, sugar-sweetened, and artificially sweetened soft drinks.

Main outcomes and measures: Total mortality and cause-specific mortality. Hazard ratios (HRs) and 95% CIs were estimated using multivariable Cox proportional hazards regression models adjusted for other mortality risk factors.

Results: In total, 521 330 individuals were enrolled. Of this total, 451 743 (86.7%) were included in the study, with a mean (SD) age of 50.8 (9.8) years and with 321 081 women (71.1%). During a mean (range) follow-up of 16.4 (11.1 in Greece to 19.2 in France) years, 41 693 deaths occurred. Higher all-cause mortality was found among participants who consumed 2 or more glasses per day (vs consumers of <1 glass per month) of total soft drinks (hazard ratio [HR], 1.17; 95% CI, 1.11-1.22; P < .001), sugar-sweetened soft drinks (HR, 1.08; 95% CI, 1.01-1.16; P = .004), and artificially sweetened soft drinks (HR, 1.26; 95% CI, 1.16-1.35; P < .001). Positive associations were also observed between artificially sweetened soft drinks and deaths from circulatory diseases (≥2 glasses per day vs <1 glass per month; HR, 1.52; 95% CI, 1.30-1.78; P < .001) and between sugar-sweetened soft drinks and deaths from digestive diseases (≥1 glass per day vs <1 glass per month; HR, 1.59; 95% CI, 1.24-2.05; P < .001).

Conclusions and relevance: This study found that consumption of total, sugar-sweetened, and artificially sweetened soft drinks was positively associated with all-cause deaths in this large European cohort; the results are supportive of public health campaigns aimed at limiting the consumption of soft drinks.

Figure.. Subgroup Analyses of the Association Between Soft Drink Consumption and All-Cause Mortality

The hazard ratios (HRs) are for comparing participants who drank ≥1 glass per day with those who had <1 glass per month. Multivariable Cox regression model adjusted for body mass index (BMI), calculated as weight in kilograms divided by height in meters squared (<22, 22 to <25, 25 to <30, 30 to <35, or ≥35); physical activity index (inactive, moderately inactive, moderately active, or active); educational status (none; primary school completed; technical or professional school; secondary school; longer education, including university; or not specified); alcohol consumption (nonconsumer, <5, 5 to <15, 15 to <30, or ≥30 g per day); smoking status and intensity (never; current: 1-15 cigarettes per day; current: 16-25 cigarettes per day; current: ≥16 cigarettes per day; former: quit ≤10 y; former: quit 11-20 y; former: quit ≥20 y; current: pipe, cigar, occasional; current or former: missing; or unknown); smoking duration (<10, 10 to <20, 20 to <30, 30 to <40, ≥40 y, or smoking duration unknown); ever use of contraceptive pill (yes, no, or unknown); menopausal status (premenopausal, postmenopausal, perimenopausal or unknown menopausal status, or surgical postmenopausal); ever use of menopausal hormone therapy (yes, no, or unknown); and intakes of total energy (kcal per day), red and processed meat (g per day), fruits and vegetables (g per day), coffee (g per day), and fruit and vegetable juice (g per day) (all continuous); and stratified by age (1-year categories), EPIC center, and sex. Sugar-sweetened and artificially sweetened soft drinks were mutually adjusted. Italy, Spain, and Sweden were excluded from the sugar-sweetened and artificially sweetened soft drinks analyses because information on type of soft drink consumption was not collected. Median alcohol consumption was 5.4 g per day. EPIC indicates European Prospective Investigation into Cancer and Nutrition.