HSN743: Assignment 2: A food-based recommendation to support health in community-dwelling older adults: the impact of sugar on cardiovascular disease risks.
Cardiovascular disease (CVD) presents a significant challenge for the ageing population, as well as for those who seek to support this population, such as caregivers, health care systems and professionals. Structural and functional changes occur to vessels throughout life, culminating in increased risk of CVD. (1) CVD includes heart, stroke and blood vessel diseases and resulted in over 43,000 Australian deaths in 2017, nearly 30% of all recorded deaths. That equates to one death every 12 minutes. Most people over the age of 65 are currently living with long-term CVD, which is largely preventable. (2)
‘Australian Heart Disease Statistics 2015’, produced by the National Heart Foundation, in collaboration with The Deakin University Heart Disease Statistics Project outlined multiple clinical and lifestyle risk factors including hypertension, cholesterol, diabetes, kidney disease, diet, smoking, overweight/ obesity, alcohol and mental health, as risk factors for CVD. The majority of these risk factors can be attributed to diet, with the main areas of focus being the consumption of fruits and vegetables, sodium, fats and added sugars. (5) The 2011/12 Australian Health Survey notes that consumption of free sugars contributes to 8.9% of daily energy for 51-70 year olds, and 9.7% for those adults over 70 years. (6) Currently the World Health Organisation recommend that total energy consumption from free sugar is less than 10%, with a further reduction to less than 5% to provide additional health benefits. (7) Despite the apparent compliance of older Australians in meeting the recommended 10% target, consideration must still be given to further reducing this amount for the additional health benefits that can be achieved.
The effects of high chronic intake of added sugars (HCIAS) in the diet affects the ageing process in multiple ways. Metabolism of fructose in the liver results in both uric acid production which is potentially damaging for cells, and de novo lipogenesis, that is, metabolic formation of fat. Excess intake of fructose, and resultant lipogenesis, can lead to development of disorders by increasing oxidative stress, inflammation, protein glycation, insulin resistance and dyslipidaemia. These features are also characteristic of ageing. Therefore, HCIAS can lead to conditions such as diabetes, heart disease and hypertension as fructose appears to mimic the effect of ageing. (8,9)
Summary of Evidence supporting reduction of added sugars and associated health benefits
A large number of studies have been undertaken to ascertain whether there is a link between sugar consumption and cardiovascular disease or its associated risk factors. Research methods vary greatly from both a design perspective, risk factors identified and methodology used. In addition to specific studies and meta-analyses listed below, multiple reviews and discussion papers have been produced addressing causal links between sugar consumption and cardiovascular disease risk and outcomes.
Epidemiological studies and experimental trials in both animal and human subjects provide evidence that suggests added sugars, in particular fructose, can increase blood pressure and heart rate and can also contribute to inflammation, insulin resistance and other metabolic conditions. (10) For the purpose of this report animal studies, and those relating specifically to children have been excluded. Sugar in various forms have been utilised in trials including sugar-sweetened beverages (SSB), dietary free sugars, high chronic intake of added sugars (HCIAS), total fructose intake and high-fructose corn syrup (HFCS). (8,10-14) Regardless of the form of sugar utilised, or reviewed in available data sets, findings consistently showed that risk factors for CVD such as hypertension, lipid profiles, obesity and metabolic disease were impacted.
Despite many reviews and trials outlining the link between sugar and cardiovascular risk factors, Rippe & Angelopoulos (2016) conclude in their review that data from sources they reviewed, as well as studies from their research laboratory did not support a link between sugar consumption at normal levels within the human diet and a variety of adverse health-related effects. (15) This outcome was supported a review and meta-analysis of a further 3 prospective cohort studies that indicated no increased risk of hypertension due to total fructose intake. (21)
Studies have also been conducted to determine outcomes of projects aimed to change SSB and water consumption in varying age groups globally. In adults, interventions have shown small improvements in relation to reduction of SSB consumption, which is similar to other dietary advice interventions. The need to assess behavioural change initiatives to decrease the intake of free sugars has been outlined, and in particular SSB consumption has been identified as a research gap, and that further investigation in to nutritional education is warranted. (16)
Table 1: Summary of Evidence of Sugar/ Fructose intake and Cardiovascular Disease
|Study Description||Sample & Characteristics||Intervention/ Methods||Main Outcomes||Conclusion|
|Jalal et al, 2010
Location: United States
Study design: cross-sectional
Population: adults with no history of hypertension
|Median fructose intake of 74g/d – equivalent to 2.5 sugary drinks per day||Increased fructose intake led to a 26, 30, and 77% higher risk for the following clinically relevant BP cut-offs: ≥135/85, ≥140/90, and ≥160/100 mmHg, respectively.||High fructose intake, in the form of added sugar is associated with higher BP levels among US adults without a history of hypertension|
|Stanhope et al, 2015
Location: United States
Study design: parallel-arm, nonrandomized, double-blinded
Population: age 18-40, BMI 18-35
|HFCS at 0%, 10%, 17.5% or 25% Ereq||Linear dose response increases of lipid/lipoprotein risk factors for CVD and uric acid, postprandial triglycerides, fasting LDL cholesterol and mean uric acid concentrations.||Epidemiologic evidence supports the risk of cardiovascular mortality is positively associated with consumption of increasing amounts of added sugars|
|Jayalath et al, 2015
Study Design: systematic review and meta-analysis of prospective cohorts
|N=240,508||Review conducted to quantify association between fructose-containing SSBs and risk of hypertension. Newcastle-Ottawa Scale for Cohort Studies was used.||12% increase in risk of developing hypertension with 1-SSB/d in both men and women with no history of hypertension||SSBs were associated with a moderate risk of developing hypertension in 6 cohorts|
|Fung et al, 2009
Study design: prospective cohort study
Population: women aged 34-59yrs. No previous diagnosis of CHD, stroke, diabetes
|Consumption of SSBs derived from FFQs Relative risks for CHD were calculated using Cox proportional hazards models and adjusted for known CVD risk factors||24 yrs of follow-up – 3105 incident cases of CHD. Cumulative average of SSB consumption (<1/mo, 1–4/mo, 2–6/wk, 1/d, and ≥2 servings/d) were 1.0, 0.96 (0.87, 1.06), 1.04 (0.95, 1.14), 1.23 (1.06, 1.43), and 1.35 (1.07, 1.69) (P for trend < 0.001)||Regular consumption of SSBs is associated with a higher risk of CHD in women, after accounting for unhealthful lifestyle and dietary factors|
|Yang et al, 2014
Location: United States
Study design: Prospective Cohort
Population: Nationally representative of US adults
|CVD mortality||National Health and Nutrition Examination Survey||There is a significant relationship between added sugar consumption and increased CVD mortality risk|
|Morenga et al, 2014
Study design: systematic review and meta-analysis of randomised controlled trials
|39 trials, with a minimum trial duration of 2 weeks.||Examination of the effects of modification of dietary free sugars on blood pressure and lipids||Higher sugar intakes raise triglycerides||Dietary sugars have a modest influence on blood pressure and serum lipids, independent of effects of sugars on body weight. The findings are sufficient to support reduction of free sugars in the diet.|
|Malik et al, 2014
Study design: systematic review of cross-sectional and prospective cohort studies
|12 studies met criteria||Exploration of the relationship between consumption of SSB and BP||Statistical significance was reported in 10 studies. 5 reported increase in mean BP, 7 reported increase in incidence of high BP||Consumption of SSBs is associated with higher BP, leading to increased incidence of hypertension. Reduction of SSB consumption should be incorporated in to lifestyle modifications for treatment of hypertension|
|Rippe & Angelopoulous, 2016
Study design: presentation of data from RCTs and presentation of findings from systematic reviews and meta-analyses
|Multiple RCTs and recent systematic reviews meta-analyses||Relationship of sugar consumption and a range of health-related issues||Energy-regulating hormones, cardiovascular disease, diabetes, besity, accumulation of liver fat and neurologic responses were reviewed. Data did not support a link between any of these and sugar consumption at normal levels in the human diet.||Data from the reviewed sources do not support linkages between sugar consumption at normal levels within the human diet and various adverse metabolic and health-related effects.|
BP: blood pressure, HFCS: high fructose corn syrup, Ereq: energy requirement, SSB: sugar-sweetened beverage, RCTs: randomised controlled trials. (
Cardiovascular disease in the leading cause of premature death globally and hypertension has been identified as a significant risk factor. There is compelling evidence from clinical trials, population studies and basic science that sugar, and in particular fructose, plays a major role in its development, as well as contributing to general cardiovascular risk. Sugar, or sucrose, is composed of glucose and fructose, and is a common ingredient in processed foods, although it is not as commonly used in these foods as HFCS. Sucrose is equal parts fructose and glucose, whereas HFCS is 55% fructose and 45% glucose. HFCS is not only used commonly in processed foods, it is also used in fruit drinks and soft drinks, that is, SSBs. (10) Free sugars refer to monosaccharides, including glucose and fructose, as well disaccharides, such as sucrose, which is also referred to as table sugar. These items are added to foods and drinks by manufacturers, cooks or consumers, and include sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates. (7)
The majority of studies reviewed, indicated a correlation between consumption of sugar and CVD risk. Although no studies specifically addressed the needs of older adults, this age group was included in some of the data sets and results from these groups were not noted as exclusions, or required any specific mention. (18, 19) The common conclusion that sugar consumption should be reduced to prevent risks associated with CVD are population general, although recommended amounts of free sugars vary amongst health advisory groups. The American Heart Association recommends 9 teaspoons for men and 6 teaspoons for women. (1) The world health organisation (WHO) recommend less than 10% of total energy intake, with an aim to reduce this to 5%. (7) The Australian Heart Foundation recommend limiting foods high in added sugar such as cakes, biscuits and sugary drinks. (2) Food Standards Australia New Zealand suggest the WHO recommendation, which they say amounts to about 12 teaspoons of free sugar per day for an adult with a healthy body mass index. (10, 20)
A meta-analysis of randomised controlled trials identified that higher sugar intakes markedly increases both systolic and diastolic blood pressures verses lower sugar intakes. It was also noted that when studies which received sugar industry funding were excluded the variance was more pronounced. (10) The review conducted by Rippe & Angelopoulos, that identified no causal link between sugar and heart disease, based on normal consumption of sugar in the human diet did not define normal levels of sugar intake in the human diet, furthermore, one of the authors has disclosed multiple conflicts of interest, including consulting fees from large multinational food and beverage companies. (15)
Obesity is noted as a risk factor for CVD. Studies conclude that the reduction in blood pressure of both normotensive and hypertensive participants obtain may result in part from the weight loss, yet there also appears to be an effect directly linked to reduction of sugar consumption. (23)
It’s never too late to make changes to one’s food choices, with the goal of achieving better health outcomes. Sugar consumption has been shown to accelerate ageing and contribute to progression or development of chronic diseases, such as cardiovascular disease. Where to begin? Start with the obvious sources of sugar – soft drinks, fruit juices, energy drinks and ready-made iced teas and flavoured waters. Stick to water, tea and coffee (skip the sugar). If you prefer flavour in your water try lemon, lime or other fresh fruit.
Many processed foods, even savoury foods, contain sugar. It can be difficult to imagine how much sugar is contained in foods and drinks, and visual representations, or converting weight on nutrition panels in to teaspoons. 4 grams of sugar is approximately 1 teaspoon. It can be quite surprising to learn how many teaspoons of sugar are contained in commonly consumed foods, such as soft drink, fruit juices, breakfast cereals and apparently healthy sweetened yoghurts. As well as cutting back on sugars in these commonly identified items as starting point, it is also worth considering those items where the sugar source is better understood, such as cakes, chocolate, biscuits and desserts. Maintaining free sugar intake at recommended levels is advised(17)
Or is it? Consumption of sugar has been linked to heart disease, particularly added sugars. It can put up your blood pressure, turn in to unhealthy fat and increase your risk of all sorts of health problems, including heart disease. It can make you age more quickly too – perhaps you feel like that’s happened already. It’s never too late to make a few small changes, they just might make all the difference.
Where to begin? Start with the obvious sources of sugar – soft drinks, fruit juices, ready-made iced teas, cordials and flavoured waters. Stick to plain water, tea and coffee (skip the sugar). If you prefer flavour in your water try lemon, lime or other fresh fruit. Or for some bubbles, try soda water.
Many processed foods, even savoury foods, contain sugar. It can be difficult to imagine how much sugar there is in food and drinks, so try converting the weight on nutrition panels in to teaspoons. 4 grams of sugar is approximately 1 teaspoon. It can be quite surprising to learn how many teaspoons of sugar are contained in commonly consumed foods, such as soft drink, fruit juices, breakfast cereals and apparently healthy sweetened yoghurts. As well as cutting back on sugars in these commonly identified items as starting point, it is also worth re-considering those items where the sugar source is better understood, such as cakes, chocolate, biscuits and desserts. (17)
Have a look at how much sugar is in common drinks – 9 teaspoons in a can of coke – 3 ½ teaspoons in a small juice popper. How about tomato sauce – there’s almost 1 teaspoon of sugar per tablespoon.
Previously the World Health Organisation recommended 12 teaspoons of sugar per day, they now suggest we aim for a maximum of 6 teaspoons of added sugar – that’s the stuff that gets added to all foods. The only allowance is for naturally occurring sugars, such as those in fruits and vegetables. (7,10) * https://lukeclarke.com.au/2016/05/31/sugar-that-drink/
- Paneni MD, Candela CD, Peter L, Lüscher TF, Camici GG. The Aging Cardiovascular System: Understanding It at the Cellular and Clinical Levels. JACC. 2017; 69 (15): 1952-67
- National Heart Foundation of Australia: Carbohydrates and Sugars: Available from: https://www.heartfoundation.org.au/healthy-eating/food-and-nutrition/carbohydrates-and-sugars
- Australian Bureau of Statistics. Australian Health Survey 2014/15: Available from:
- Australian Bureau of Statistics. Australian Health Survey 2011/12: Available from: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4364.0.55.011~2011-12~Main%20Features~Consumption%20of%20Added%20Sugars%20-%20A%20comparison%20of%201995%20to%202011-12~20
- Australian Heart Disease Statistics 2015. Available at: https://www.heartfoundation.org.au/images/uploads/publications/RES-115-Aust_heart_disease_statstics_2015_WEB.PDF
- Australian Bureau of Statistics: Australian Health Survey: consumption of added sugars, 2011-12. Available at: http://www.abs.gov.au/ausstats/abs@.nsf/lookup/4364.0.55.011main+features12011-12
- World Health Organisation: WHO calls on countries to reduce sugars intake among adults and children. Available at: https://www.who.int/mediacentre/news/releases/2015/sugar-guideline/en/
- Gatineau E, Polakof S, Dardevet D, Mosoni L. Similarities and interactions between the ageing process and high chronic intake of added sugars. Nutrition Research Reviews. 2017;30(02):191-207.
- Tappy L, Lê K. Metabolic Effects of Fructose and the Worldwide Increase in Obesity. Physiological Reviews. 2010;90(1):23-46.
- DiNicolantonio J, Lucan S. The wrong white crystals: not salt but sugar as aetiological in hypertension and cardiometabolic disease. Open Heart. 2014;1(1):e000167.
- Stanhope K, Medici V, Bremer A, Lee V, Lam H, Nunez M et al. A dose-response study of consuming high-fructose corn syrup–sweetened beverages on lipid/lipoprotein risk factors for cardiovascular disease in young adults. The American Journal of Clinical Nutrition. 2015;101(6):1144-1154.
- Jayalath V, Sievenpiper J, de Souza R, Ha V, Mirrahimi A, Santaren I et al. Total Fructose Intake and Risk of Hypertension: A Systematic Review and Meta-Analysis of Prospective Cohorts. Journal of the American College of Nutrition. 2014;33(4):328-339.
- Jayalath V, de Souza R, Ha V, Mirrahimi A, Blanco-Meija S et al. Sugar-sweetened beverage consumption and incident hypertension: a systematic review and meta-analysis of prospective cohorts. The American Journal of Clinical Nutrition. 2015: 102: 914-21
- Te Morenga L, Howatson A, Jones R, Mann J. Dietary sugars and cardiometabolic risk: systematic review and meta-analyses of randomized controlled trials of the effects on blood pressure and lipids. The American Journal of Clinical Nutrition. 2014;100(1):65-79.
- Rippe J, Angelopoulos T. Sugars, obesity, and cardiovascular disease: results from recent randomized control trials. European Journal of Nutrition. 2016;55(S2):45-53.
- Vargas-Garcia EJ, Evans CEL, Prestwich A, Sykes-Muskett BJ, Hoosen J et al. Interventions to reduce consumption of sugar-sweetened beverages or increase water intake: evidence from a systematic review and meta-analysis. Obesity Reviews. 2018: 18: 1350-63.
- Thornley S. Tayler R, Sikaris K. Sugar restriction: the evidence for a drug-free intervention to reduce cardiovascular disease risk. Internal Medicine Journal. 2012.
- Ferder L, Ferder M, Inserra F. The Role of High-Fructose Corn Syrup in Metabolic Syndrome and Hypertension. Current Hypertension Reports. 2010;12(2):105-112.
- Yang Q, Zhang Z, Gregg EW, Flanders WD, Merritt R et al. Added sugar intake and cardiovascular diseases mortality among US adults. JAMA Inter Med. 2014 Apr: 174 (4); 516-24.
- Food Standards Australia: Sugar. Feb 2018. Available at: http://www.foodstandards.gov.au/consumer/nutrition/Pages/Sugar.aspx
- Fung T, Malik V, Rexrode K, Manson J, Willett W, Hu F. Sweetened beverage consumption and risk of coronary heart disease in women. The American Journal of Clinical Nutrition. 2009;89(4):1037-1042.
- Jalal D, Smits G, Johnson R, Chonchol M. Increased Fructose Associates with Elevated Blood Pressure. Journal of the American Society of Nephrology. 2010;21(9):1543-1549.
- Nguyen S, Lustig R. Just a spoonful of sugar helps the blood pressure go up. Expert Review of Cardiovascular Therapy. 2010;8(11):1497-1499.