Sugar-Sweetened Beverage, Diet Soda, and Nonalcoholic Fatty Liver Disease Over 6 Years: The Framingham Heart Study

Clin Gastroenterol Hepatol. 2022 Nov;20(11):2524-2532.e2. doi: 10.1016/j.cgh.2021.11.001. Epub 2021 Nov 6.


Background & aims: Nonalcoholic fatty liver disease (NAFLD) is associated with sugar-sweetened beverage (SSB) consumption in cross-sectional studies. In a prospective cohort, we examined the association of beverage consumption (SSB and diet soda) with incident NAFLD and changes in hepatic fat in the Framingham Heart Study (FHS).

Methods: We conducted a prospective observational study of participants from the FHS Third Generation and Offspring cohorts who participated in computed tomography sub-studies. Participants were classified according to their average SSB or diet soda consumption, which was derived from baseline and follow-up food frequency questionnaires: non-consumers (0-<1/month), occasional consumers (1/month-<1/week), and frequent consumers (≥1/week-≥1/day). Hepatic fat was quantified by the liver fat attenuation measurements on computed tomography scan. The primary dependent variable was incident NAFLD; secondarily, we investigated change in liver fat.

Results: The cohorts included 691 Offspring (mean age, 62.8 ± 8.2 years; 57.7% women) and 945 Third Generation participants (mean age, 48.4 ± 6.3 years; 46.6% women). In the Offspring cohort, there was a dose-response relationship with SSB consumption and incident NAFLD. Frequent SSB consumers had 2.53 times increased odds of incident NAFLD compared with non-consumers (95% confidence interval, 1.36-4.7) after multivariable analysis. For Offspring cohort participants, occasional and frequent consumers of SSB had a more adverse increase in liver fat compared with non-consumers.

Conclusions: Higher average SSB intake is associated with increase in liver fat over 6 years of follow-up and increased odds of incident NAFLD especially among the older cohort, whereas no consistent association was observed for the younger Third Generation cohort.

Keywords: Diet Soda; Fructose; Hepatic Steatosis; Liver Fat; NAFLD; Sugar-Sweetened Beverage.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Cross-Sectional Studies
  • Diet / adverse effects
  • Female
  • Humans
  • Longitudinal Studies
  • Male
  • Middle Aged
  • Non-alcoholic Fatty Liver Disease* / epidemiology
  • Non-alcoholic Fatty Liver Disease* / etiology
  • Prospective Studies
  • Sugar-Sweetened Beverages* / adverse effects