Association of Long-term Consumption of Sugar-Sweetened and Artificially Sweetened Beverages with Total and Cause-specific Mortality

By Heather Nelson Cortes, PhD and Kevin C Maki, PhD

In the United States, sugar sweetened beverages (SSBs) account for the largest source of added sugar in the diet 1,2.  These types of drinks (e.g., carbonated, noncarbonated, fruit, sports) have added caloric sweeteners like high fructose corn syrup, sucrose, or fruit juice concentrates.  Currently it is recommended that adults consume no more than 10% of their total energy intake from added sugar 3.

While consumption rates of SSBs had been declining in the US over the past 10 years, recent research has suggested a reversal in that trend, with increased consumption among adults of all ages averaging around 145 kcal/day (6% of energy)4.  In younger adults, SSBs are responsible for 9.3% of daily calories in men and 8.2% of daily calories in women 5-7.

Studies have shown a positive association between intake of SSBs and weight gain, as well as higher risks of type 2 diabetes, coronary heart disease and stroke 8-11.  Artificially sweetened beverages (ASBs) are used as alternatives to the calorically heavy SSBs, yet there has been little research on the long-term health effects of ASBs or on the relationship between SSB consumption and total mortality.

In an analysis of two ongoing prospective cohort studies, Malik et al. examined the association between intakes of SSBs and ASBs with total and cause-specific mortality 12.  The analysis included data from the Nurses’ Health Study (NHS) and the Health Professionals Follow-up Study (HPFS).  The NHS study has been collecting data since 1976 and includes 121,700 female nurses, age 30-55 years at study entry.  The HPFS began in 1986 and includes 51,529 male health professionals, age 40-75 years at entry. 

Mean consumption of SSBs decreased in both cohorts over the follow-up periods, which were 34 years in the NHS and 28 years in the HPFS.  Intakes of SSBs and ASBs were inversely correlated in both the NHS (r = −0.06, P < 0.001) and the HPFS (r = −0.16, P < 0.001).  Overall, there were 36,436 deaths, including 7,896 from cardiovascular disease (CVD) and 12,380 from cancer during a total of 3,415,564 person-years of follow-up.

After adjusting for major diet and lifestyle factors, consumption of SSBs was associated with a higher risk of total mortality (Table).  SSBs were also associated with increased CVD mortality (hazard ratio comparing extreme categories of 1.31 [95% confidence interval, 1.15-1.50], P trend < 0.0001) and cancer mortality (1.16 [1.04-1.29], P trend = 0.0004).  ASB intake was associated with increased risk for total and CVD mortality only in the highest intake group (Table).  Interestingly, intake of ASBs was associated with total mortality in the NHS, but not the HPFS (P interaction = 0.01).  ASBs were not associated with cancer mortality in either cohort.



Table:  SSB and ASB Consumption and Mortality Risk (Total, CVD, Cancer)

Pooled Hazard Ratios (95% confidence intervals) from NHS and HPFS







P trend

Total Mortality





(0.98, 1.04)


(1.03, 1.09)


(1.09, 1.19)


(1.13, 1.28)






(0.93, 0.99)


(0.95, 1.00)


(0.94, 1.03)


(1.02, 1.12)


CVD Mortality




(1.00, 1.12)


(1.04, 1.17)


(1.08, 1.31)


(1.15, 1.50)





(0.87, 1.00)


(0.89, 1.00)


(0.94, 1.12)


(1.02, 1.25)


Cancer Mortality




(0.98, 1.08)


(1.01, 1.11)


(1.03, 1.21)


(1.04, 1.29)





(0.96, 1.07)


(0.94, 1.04)


(0.93, 1.07)


(0.96, 1.12)



Comment.  Results from this study highlight the importance of minimizing SSB intake because consumption of SSBs has been consistently associated with adverse health outcomes and a less favorable cardiometabolic risk factor profile.8-11  Substituting ASBs for SSBs will help decrease added sugar intake, but it is important to note that the possible health impacts of long-term consumption have not been well documented.  It is uncertain whether the modest increases in total (4%) and CVD (13%) mortality associated with consuming ≥2 ASBs per day represent causal relationships.  Nevertheless, it is reasonable to recommend moderation in the consumption of these products.



  1. Hu FB, Malik VS. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav. 2010;100:47–54.
  2. National Cancer Institute: Division of Cancer Control & Population Sciences. Epidemiology and Genomics Research Program. Sources of Calories from Added Sugars among the US population, 2005–2006. Updated April 20, 2018.
  3. S. Department of Health and Human Services and U.S. Department of 
Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015.
  4. Welsh JA, Sharma AJ, Grellinger L, Vos MB. Consumption of added sugars is decreasing in the United States. Am J Clin Nutr. 2011;94:726–734.
  5. Ogden CL, Kit BK, Carroll MD, Park S. Consumption of sugar drinks in the United States, 2005–2008. NCHS Data Brief. 2011:1–8. 

  6. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among U.S. adults, 2011–2014. NCHS Data Brief. 2017:1–8. 

  7. Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr. 2013;98:1084–1102.
  8. Malik VS, Popkin BM, Bray GA, Després JP, Willett WC, Hu FB. Sugar- sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33:2477–2483.
  9. Fung TT, Malik V, Rexrode KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart disease in women. Am J Clin Nutr. 2009;89:1037–1042.
  10. de Koning L, Malik VS, Kellogg MD, Rimm EB, Willett WC, Hu FB. Sweetened beverage consumption, incident coronary heart disease, and biomarkers of risk in men. Circulation. 2012;125:1735–41, S1.
  11. Bernstein AM, de Koning L, Flint AJ, Rexrode KM, Willett WC. Soda consumption and the risk of stroke in men and women. Am J Clin Nutr. 2012;95:1190–1199.
  12. Malik VS, Li Y, Pan A, De Koning L, Schernhammer E, Willett WC, Hu FB. Long-term consumption of sugar-sweetened and artificially sweetened beverages and risk of mortality in US adults.  2019;139: doi: 10.1161/circulationaha.118.037401.



Photo by

Leave a Comment