Accepted Manuscript Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure Feng J. He , PhD Graham A. MacGregor , MD PII:
S0002-9149(14)01089-3
DOI:
10.1016/j.amjcard.2014.05.004
Reference:
AJC 20452
To appear in:
The American Journal of Cardiology
Received Date: 1 May 2014 Accepted Date: 6 May 2014
Please cite this article as: He FJ, MacGregor GA, Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure, The American Journal of Cardiology (2014), doi: 10.1016/j.amjcard.2014.05.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure
RI PT
In their interesting review article, Malik et al1 do not seem to consider the underlying mechanism by which sugar-sweetened soft drink consumption is
associated with increased blood pressure. For instance, there is clear evidence for a
SC
causal relation between salt intake and total fluid consumption,2 as well as sugarsweetened soft drink consumption,3 an important and very relevant point which Malik
M AN U
et al failed to acknowledge. A carefully controlled metabolic study in adult humans where salt intake was changed, has quantified the relation between the change in salt intake and the subsequent change in fluid consumption.2 A study in 10,074 free living individuals across the world showed an identical relation between usual salt
TE D
and fluid intake.2 An analysis of the National Diet and Nutrition Survey dataset showed that, in free living children in Great Britain, the same relation held true.3 Similar findings have also been reported in the USA and Australia.4 5 There is,
EP
therefore, no doubt that in humans, like other mammals, salt is a major drive to thirst and, an increase in salt intake will increase the amount of fluid consumed, and if part
AC C
of this fluid is in the form of soft drinks, they will be increased proportionately. It is therefore likely that the increased salt intake is, at least, partially responsible for the increase in blood pressure and the increase in soft drink consumption. In other words, the observed association between sugar-sweetened soft drink consumption and blood pressure may be, in part, mediated by salt intake.
As Malik et al rightly pointed out, sugar-sweetened soft drinks are the largest source of added sugar in our diet. Added sugar is a major hidden source of calories 1
ACCEPTED MANUSCRIPT and contributes to obesity and type 2 diabetes.6-8 Some studies also suggest that the role of sugar in soft drinks in obesity might be key because it provides no feeling of satiation.9 It is well established that obesity is associated with an increased blood pressure. Additionally, sugar in soft drinks stimulates insulin secretion which could
RI PT
lead to sodium and water retention10 and, thereby, possibly increasing blood
pressure. The suggested mechanism for the links between salt intake, sugar-
SC
sweetened soft drink consumption and blood pressure is shown in Figure.
Raised blood pressure throughout its range is a major cause of cardiovascular
M AN U
disease, accounting for 62% of strokes and 49% of coronary heart disease.11 A reduction in population salt intake which can easily be made by slowly reducing the amounts of salt added to foods by the food industry, will lead to a reduction in population blood pressure and cardiovascular mortality, as demonstrated in the UK12
TE D
and Finland.13 Furthermore, a reduction in salt intake will cause a reduction in sugarsweetened soft drink consumption and, thereby, a decrease in obesity and type II
EP
diabetes.
Efforts to reduce soft drink consumption combined with a gradual reduction in
AC C
the amounts of sugar added to soft drinks will provide additional beneficial effects on health. An action group (Action on Sugar)14 was recently set up with a mission to achieve a gradual and sustained reduction in the amounts of sugar added to foods and drinks, following a similar model to the UK salt reduction programme15 pioneered by Consensus Action on Salt and Health (CASH).16 This model has become one of the most successful nutritional policies in the UK since the Second World War,17 by setting progressively lower salt targets for over 80 categories of foods for the food industry to achieve within a certain time frame.15 As this is done slowly, people do 2
ACCEPTED MANUSCRIPT not notice the difference in taste. A reduction in population salt and sugar intake, even by a small amount, will have a major beneficial effect on health along with major cost savings.
RI PT
Feng J He, PhD. Graham A MacGregor, MD London, UK
AC C
EP
TE D
M AN U
SC
1 May 2014
3
ACCEPTED MANUSCRIPT
1. Malik AH, Akram Y, Shetty S, Malik SS, Yanchou Njike V. Impact of SugarSweetened Beverages on Blood Pressure. Am J Cardiol 2014;113:1574-1580. 2. He FJ, Markandu ND, Sagnella GA, MacGregor GA. Effect of salt intake on renal
RI PT
excretion of water in humans. Hypertension 2001;38:317-320.
3. He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink
consumption in children and adolescents: a link to obesity? Hypertension
SC
2008;51:629-634.
M AN U
4. Grimes CA, Wright JD, Liu K, Nowson CA, Loria CM. Dietary sodium intake is associated with total fluid and sugar-sweetened beverage consumption in US children and adolescents aged 2-18 y: NHANES 2005-2008. Am J Clin Nutr 2013;98:189-196.
TE D
5. Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugarsweetened beverage consumption, and obesity risk. Pediatrics 2013;131:14-21. 6. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on
EP
nutrition and health: a systematic review and meta-analysis. Am J Public Health
AC C
2007;97:667-675.
7. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 2013;346:e7492. 8. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J, American Heart Association Nutrition Committee of the Council on Nutrition PA, Metabolism, the Council on E, Prevention. Dietary
4
ACCEPTED MANUSCRIPT sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009;120:1011-1020. 9. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: effects on food intake
RI PT
and body weight. Int J Obes Relat Metab Disord 2000;24:794-800. 10. Rocchini AP, Katch V, Kveselis D, Moorehead C, Martin M, Lampman R, Gregory M. Insulin and renal sodium retention in obese adolescents.
SC
Hypertension 1989;14:367-374.
11. World Health Report 2002: Reducing risks, promoting healthy life. Geneva,
M AN U
Switzerland: World Health Organisation, 2002. www.who.int/whr/2002 (Accessed 3 June 2013).
12. He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart
TE D
disease mortality. BMJ Open 2014;4:e004549.
13. Karppanen H, Mervaala E. Sodium intake and hypertension. Prog Cardiovasc
EP
Dis 2006;49:59-75.
14. MacGregor GA, Hashem KM. Action on sugar--lessons from UK salt reduction
AC C
programme. Lancet 2014;383:929-931. 15. He FJ, Brinsden HC, Macgregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2013:advance online publication, 31 October 2013; doi:2010.1038/jhh.2013.2105. 16. Consensus Action on Salt and Health. www.actiononsalt.org.uk/ (Access verified July 23, 2012). 17. Winkler JT. Obesity exposé offers slim pickings. BMJ 2012;345:e4465.
5
ACCEPTED MANUSCRIPT Figure caption: Mechanism for the links between salt intake, sugar-sweetened soft
AC C
EP
TE D
M AN U
SC
RI PT
drink consumption and blood pressure (BP).
6
ACCEPTED MANUSCRIPT
RI PT
Salt Intake ↑
M AN U
SC
Soft drinks ↑ Insulin ↑
TE D
Gut sodium absorption
AC C
EP
Sodium and water retention
BP ↑
Calorie ↑
Obesity ↑
S0002-9149(14)01089-3
DOI:
10.1016/j.amjcard.2014.05.004
Reference:
AJC 20452
To appear in:
The American Journal of Cardiology
Received Date: 1 May 2014 Accepted Date: 6 May 2014
Please cite this article as: He FJ, MacGregor GA, Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure, The American Journal of Cardiology (2014), doi: 10.1016/j.amjcard.2014.05.004. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Salt Intake, Sugar-sweetened Soft Drink Consumption and Blood Pressure
RI PT
In their interesting review article, Malik et al1 do not seem to consider the underlying mechanism by which sugar-sweetened soft drink consumption is
associated with increased blood pressure. For instance, there is clear evidence for a
SC
causal relation between salt intake and total fluid consumption,2 as well as sugarsweetened soft drink consumption,3 an important and very relevant point which Malik
M AN U
et al failed to acknowledge. A carefully controlled metabolic study in adult humans where salt intake was changed, has quantified the relation between the change in salt intake and the subsequent change in fluid consumption.2 A study in 10,074 free living individuals across the world showed an identical relation between usual salt
TE D
and fluid intake.2 An analysis of the National Diet and Nutrition Survey dataset showed that, in free living children in Great Britain, the same relation held true.3 Similar findings have also been reported in the USA and Australia.4 5 There is,
EP
therefore, no doubt that in humans, like other mammals, salt is a major drive to thirst and, an increase in salt intake will increase the amount of fluid consumed, and if part
AC C
of this fluid is in the form of soft drinks, they will be increased proportionately. It is therefore likely that the increased salt intake is, at least, partially responsible for the increase in blood pressure and the increase in soft drink consumption. In other words, the observed association between sugar-sweetened soft drink consumption and blood pressure may be, in part, mediated by salt intake.
As Malik et al rightly pointed out, sugar-sweetened soft drinks are the largest source of added sugar in our diet. Added sugar is a major hidden source of calories 1
ACCEPTED MANUSCRIPT and contributes to obesity and type 2 diabetes.6-8 Some studies also suggest that the role of sugar in soft drinks in obesity might be key because it provides no feeling of satiation.9 It is well established that obesity is associated with an increased blood pressure. Additionally, sugar in soft drinks stimulates insulin secretion which could
RI PT
lead to sodium and water retention10 and, thereby, possibly increasing blood
pressure. The suggested mechanism for the links between salt intake, sugar-
SC
sweetened soft drink consumption and blood pressure is shown in Figure.
Raised blood pressure throughout its range is a major cause of cardiovascular
M AN U
disease, accounting for 62% of strokes and 49% of coronary heart disease.11 A reduction in population salt intake which can easily be made by slowly reducing the amounts of salt added to foods by the food industry, will lead to a reduction in population blood pressure and cardiovascular mortality, as demonstrated in the UK12
TE D
and Finland.13 Furthermore, a reduction in salt intake will cause a reduction in sugarsweetened soft drink consumption and, thereby, a decrease in obesity and type II
EP
diabetes.
Efforts to reduce soft drink consumption combined with a gradual reduction in
AC C
the amounts of sugar added to soft drinks will provide additional beneficial effects on health. An action group (Action on Sugar)14 was recently set up with a mission to achieve a gradual and sustained reduction in the amounts of sugar added to foods and drinks, following a similar model to the UK salt reduction programme15 pioneered by Consensus Action on Salt and Health (CASH).16 This model has become one of the most successful nutritional policies in the UK since the Second World War,17 by setting progressively lower salt targets for over 80 categories of foods for the food industry to achieve within a certain time frame.15 As this is done slowly, people do 2
ACCEPTED MANUSCRIPT not notice the difference in taste. A reduction in population salt and sugar intake, even by a small amount, will have a major beneficial effect on health along with major cost savings.
RI PT
Feng J He, PhD. Graham A MacGregor, MD London, UK
AC C
EP
TE D
M AN U
SC
1 May 2014
3
ACCEPTED MANUSCRIPT
1. Malik AH, Akram Y, Shetty S, Malik SS, Yanchou Njike V. Impact of SugarSweetened Beverages on Blood Pressure. Am J Cardiol 2014;113:1574-1580. 2. He FJ, Markandu ND, Sagnella GA, MacGregor GA. Effect of salt intake on renal
RI PT
excretion of water in humans. Hypertension 2001;38:317-320.
3. He FJ, Marrero NM, MacGregor GA. Salt intake is related to soft drink
consumption in children and adolescents: a link to obesity? Hypertension
SC
2008;51:629-634.
M AN U
4. Grimes CA, Wright JD, Liu K, Nowson CA, Loria CM. Dietary sodium intake is associated with total fluid and sugar-sweetened beverage consumption in US children and adolescents aged 2-18 y: NHANES 2005-2008. Am J Clin Nutr 2013;98:189-196.
TE D
5. Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugarsweetened beverage consumption, and obesity risk. Pediatrics 2013;131:14-21. 6. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on
EP
nutrition and health: a systematic review and meta-analysis. Am J Public Health
AC C
2007;97:667-675.
7. Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ 2013;346:e7492. 8. Johnson RK, Appel LJ, Brands M, Howard BV, Lefevre M, Lustig RH, Sacks F, Steffen LM, Wylie-Rosett J, American Heart Association Nutrition Committee of the Council on Nutrition PA, Metabolism, the Council on E, Prevention. Dietary
4
ACCEPTED MANUSCRIPT sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation 2009;120:1011-1020. 9. DiMeglio DP, Mattes RD. Liquid versus solid carbohydrate: effects on food intake
RI PT
and body weight. Int J Obes Relat Metab Disord 2000;24:794-800. 10. Rocchini AP, Katch V, Kveselis D, Moorehead C, Martin M, Lampman R, Gregory M. Insulin and renal sodium retention in obese adolescents.
SC
Hypertension 1989;14:367-374.
11. World Health Report 2002: Reducing risks, promoting healthy life. Geneva,
M AN U
Switzerland: World Health Organisation, 2002. www.who.int/whr/2002 (Accessed 3 June 2013).
12. He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart
TE D
disease mortality. BMJ Open 2014;4:e004549.
13. Karppanen H, Mervaala E. Sodium intake and hypertension. Prog Cardiovasc
EP
Dis 2006;49:59-75.
14. MacGregor GA, Hashem KM. Action on sugar--lessons from UK salt reduction
AC C
programme. Lancet 2014;383:929-931. 15. He FJ, Brinsden HC, Macgregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens 2013:advance online publication, 31 October 2013; doi:2010.1038/jhh.2013.2105. 16. Consensus Action on Salt and Health. www.actiononsalt.org.uk/ (Access verified July 23, 2012). 17. Winkler JT. Obesity exposé offers slim pickings. BMJ 2012;345:e4465.
5
ACCEPTED MANUSCRIPT Figure caption: Mechanism for the links between salt intake, sugar-sweetened soft
AC C
EP
TE D
M AN U
SC
RI PT
drink consumption and blood pressure (BP).
6
ACCEPTED MANUSCRIPT
RI PT
Salt Intake ↑
M AN U
SC
Soft drinks ↑ Insulin ↑
TE D
Gut sodium absorption
AC C
EP
Sodium and water retention
BP ↑
Calorie ↑
Obesity ↑
