Sugar-Sweetened Beverage Consumption and Incident Cardiovascular Risk Factors: The Multi-Ethnic Study of Atherosclerosis

1. Sugar-Sweetened Beverage Consumption and Incident Cardiovascular Risk Factors:The Multi-Ethnic Study of Atherosclerosis(MESA) Christina Shay PhD MA1Jennifer Nettleton PhD2; Pamela Lutsey PhD MPH3; Tamar PolonskyMD4; Mercedes Carnethon PhD4; Linda Van Horn PhD RD4, Gregory Burke MD MSc5 1Dept of Biostatistics and Epidemiology, Univ of Oklahoma Health Sciences Ctr, Oklahoma City, OK ; 2Div of Epidemiology, Human Genetics and Environmental Sciences, Univ of Texas School of Public Health, Houston, TX; 3Div of Epidemiology and Community Health, Univ of Minnesota, School of Public Health, Minneapolis 4Dept of Preventive Medicine, Feinberg School of Medicine, Northwestern Univ, Chicago, IL; 5Div of Public Health Sciences, Wake Forest Univ Health Science, Winston-Salem, NC Corresponding Author: christina-shay@ouhsc.edu

2. Background • Sugar-sweetened beverage (SSB) consumption has been associated with weight gain and obesity, dyslipidemia, hyperglycemia, type 2 diabetes, and increased risk for cardiovascular (CV) events • The association between SSB consumption and development of CV risk factors has not been extensively examined in large, prospective, multi-ethnic cohorts

3. Objective • To quantify the association between SSB consumption and risk for developing individual CV risk factors in men and women in the Multi-Ethnic Study of Atherosclerosis (MESA)

4. MESA Study Description 6,814 participants recruited in 2000-2002 Field Centers: - Baltimore - New York - Chicago - St. Paul - Los Angeles - Winston-Salem • 45-84 years, free of clinical cardiovascular disease • 57% women • 38% Non-Hispanic White, 28% African-American, 22% Hispanic, 12% Chinese American

5. Assessment of SSB Intake • Food Frequency Questionnaire (FFQ) was used to measure SSB consumption at the first exam (2000-2002) • The FFQ specifically asked about consumption of “regular soft drinks, soda, sweetened mineral water (not diet), and nonalcoholic beer” • SSB intake was categorized into the following groups: 0-<1, 1-<2, and 2+ servings per day

6. CV Risk Factors Definitions (1) • Weight Gain: Weight on any follow-up exam or average of all exam weight measurements >3% higher than baseline • Increased Waist Circumference (WC): WC from any follow-up exam or average of all exam WC measurements >3% higher than baseline • High Triglycerides: HDL >40 mg/dL (men), > 50mg/dL (women), LDL <160mg/dL, and triglycerides >150mg/dL

7. CV Risk Factors Definitions (2) • Low HDL cholesterol: HDL <40mg/dL(men), <50 mg/dL (women), LDL <160mg/dL, and triglycerides <150mg/dL • Impaired Fasting Glucose: Fasting plasma glucose 100-125 mg/dL • Type 2 Diabetes (T2D): Fasting glucose ≥126 mg/dL, medication use for T2D or self-reported T2D

8. Selection of Study Participants for the Current Study Excluded Participants No follow up exams (n=761) Type 2 diabetes at baseline(n=773) BMI <18.5 kg/m2at baseline (n=37) Missing covariates of interest (n=1,077) Additional Exclusions Lipid Medication Use (n=2,552) Impaired fasting glucose at baseline (n=729) 6,814 MESA participants ages 45-84 and free of clinical CVD at first exam General Analysis Sample(n=4,166) Lipid Analyses (n=1,614) IGT Analyses (n=3,437)

9. Statistical Analyses • Cox proportional hazards regression used estimate hazard ratios • All risk estimates adjusted for: • Age • Sex • Race/ethnicity • Study center • Educational attainment • Intentional exercise • Smoking status • Dietary intake (i.e., total energy, fiber, saturated fat, cholesterol, fruits and vegetables, sodium) • Family history of T2D (for T2D incidence) • Time-varying BMI and WC

10. Results

11. Table 1: MESA Baseline Characteristics According to SSB Consumption IQR, interquartile range; Significantly different across groups, *p-value < 0.01, **p-value < 0.001

12. Hazard Ratios (95% CI) for Weight Gain According to Level of Sugar-Sweetened Beverage Consumption: The Multi-Ethnic Study of Atherosclerosis (MESA) MenWomen Hazard Ratios (95% C.I.)

13. Hazard Ratios (95% CI) for IncreasedWaist Circumference According to Level of Sugar-Sweetened Beverage Consumption: The Multi-Ethnic Study of Atherosclerosis (MESA) MenWomen Hazard Ratios (95% C.I.)

14. Hazard Ratios (95% CI)* for High Triglycerides According to Level of Sugar-Sweetened Beverage Consumption: The Multi-Ethnic Study of Atherosclerosis (MESA) MenWomen Hazard Ratios (95% C.I.)

15. Hazard Ratios (95% CI) for Low HDL Cholesterol According to Level of Sugar-Sweetened Beverage Consumption: The Multi-Ethnic Study of Atherosclerosis (MESA) MenWomen Hazard Ratios (95% C.I.)

16. Hazard Ratios (95% CI) for Impaired Fasting Glucose According to Level of Sugar-Sweetened Beverage Consumption: The Multi-Ethnic Study of Atherosclerosis (MESA) MenWomen Hazard Ratios (95% C.I.)

17. Hazard Ratios (95% CI) for Type 2 Diabetes According to Level ofSugar-Sweetened Beverage Consumption: The Multi-Ethnic Study of Atherosclerosis (MESA) MenWomen Hazard Ratios

18. Summary • Women who consumed 2+ SSBs per day exhibited higher risk for developing: • high triglycerides • impaired glucose tolerance • increased waist circumference compared to women who consumed <1 SSB per day • These associations remained even after accounting for baseline and time varying BMI and WC

19. Strengths and Limitations Strengths • The MESA study is a large, population-based cohort designed to examine the development of CVD risk factors Limitations • Food frequency item used likely to not have captured all types of SSBs consumed

20. American Beverage Association "This type of study cannot show that drinking sugar-sweetened beverages causes increased risk for cardiovascular disease. It simply looks at associations between the two, which could be the result of numerous other confounding factors.”

21. Conclusions • The influence of SSBs consumption on cardiovascularrisk is complex and may not be the same between middle- and older-aged men and women • Women exhibit lower energy requirements compared to men and may therefore experience higher CV risk when a greater proportion of calories is consumed in the form of SSBs

22. Acknowledgements • Co-Authors: Jennifer Nettleton, Pamela Lutsey, Tamar Polonsky, Linda Van Horn, Gregory Burke • MESA’s Funding Agency: National, Heart, Lung, and Blood Institute (NHLBI) THANK YOU

23. Table 1: Characteristics According to SSB Consumption at First Exam IQR, interquartile range; Significantly different across groups, *p-value < 0.01, **p-value < 0.001

24. Sample Sizes