Healthy Beverage Choices and Prevention of Obesity, Diabetes, and 

Cardiometabolic Diseases

Frank B. Hu, MD, PhDProfessor of Nutrition and Epidemiology

Harvard School of Public HealthProfessor of Medicine

Harvard Medical School

Harvard Public Health Review

What are Sugar-Sweetened Beverages?Examples

Sodas Fruit Drinks Energy Drinks

Coke ®

Pepsi ®

Mountain Dew ®

Orange SodaRoot BeerSprite ®

7-Up ®

Capri Sun ®Fruitopia ®

Hawaiian Punch ®

Hi-C ®

Kool-Aid ®

Minute Maid ®

Snapple juices ®

Adrenaline Rush ®

Full Throttle ®

MDX ®

No Fear ®

RockStar ®EnergyVault ®

Sports DrinksGatorade ®

Powerade ®

Wang et al. Pediatrics. 2008

Per capita calories from SSB in US children: 1988-2004

Soft drink ingredients

• Energy: 12-14 kcal/ounce

or ~120-150 kcal/12 ounce can

• Sugars: 3.1-3.6 g/ounce

(~10 tsp/12 ounce can)

• Sweetened by high fructose corn syrups (55%

fructose and 40% glucose)

0

10

20

30

40

50

60

70

Year

1969

1973

1977

1981

1985

1989

1993

1997

US Per Capita High Fructose Corn Syrup Disappearance1967 – 2000, Pounds / Year

SSB and ObesityStrong evidence points to a positive relationship between SSB and obesity

Teens: For every can of sugared soda per day, increased risk of obesity by 60%

In adults, regular consumption of SSB leads to greater weight gain

Source: Ludwig et al., Lancet, 2001; Schulze et al., JAMA, 2004

SSB and Obesity: Why? Fluids are not be as satiating as solid foods.

The body doesn't seem to "register" fluid calories as carefully as it does those from solid food.

Sweet‐tasting soft drinks might stimulate the appetite for other sweet, high‐carbohydrate foods.

1.501.85

1.061.001.39 1.41

1.00 1.11

0.00.51.01.52.02.5

<1/mo 1-4/mo 2-6/wk >=1/dSugar-sweetened soft drink consumption

Rel

ativ

e R

isk

multivariate adjusted multivariate + BMI

P<0.001 for trend

SSB and Risk of Type 2 Diabetes in the Nurses’ Health Study

Emerging evidence on heart disease The Nurses' Health Study, which tracked the health of nearly 90,000 women over two decades, found that women who drank more than two servings of SSB each day had a 40 percent higher risk of heart attacks or death from heart disease than women who rarely drank SSB.

Frequent consumption of SSB is also associated with high blood pressure and high triglycerides.

Fung et al, AJCN, 2009

SSB and Risk of Gout Gout is inflammatory arthritis with uric acid building up in the joints

Convincing evidence that regular consumption of SSB induces the production of uric acid and leads to high levels of blood uric acid.

One serving per day of SSB is associated with 50% increased risk of developing gout.

Juice: A healthier option?

Source: www.odwalla.com

Which has the most sugar?per 12 ounce serving

Source: www.thecoca-colacompany.com/presscenter/imagegallery.html, www.pepsiproductfacts.com/infobyproduct.php, http://www.welchs.com/products/juices-and-drinks/100-percent-grape-juice/100-percent-grape-juice, http://pomwonderful.com/products/

150 calories 195 calories 255 calories 240 calories

per 12 ounce serving

100% fruit juice

Fruit juice has vitamins and minerals, but it is high in calories, so stick to no more than a small glass (four to six ounces) a day.

Healthier beverage alternativesWater Coffee and tea Diet soda ?Milk ?

Beverage choices and weight gain

Changes in beverage intake and changes in weight

An Pan, 2011 (unpublished data)

Weight change associated with each increased daily servings, per 4-y period (Ib)

Beverage substitutions and type 2 diabetes

An Pan, 2011 (unpublished data)

Substitution model for type 2 diabetes

0.7 0.75 0.8 0.85 0.9 0.95 1

SSB by water

SSB by coffee

SSB by milk

SSB by tea

Fruit juice by water

Fruit juice by coffee

Fruit juice by milk

Fruit juice by tea

Diet Soda Some long‐term studies show that regular consumption of diet soda reduces calories and promotes weight loss or maintenance. Others show no effect, while some show weight gain.

“Diet” drinks with artificial sweeteners may condition our taste buds to crave super‐sweet foods.

SSB vs. Diet Sodas and Diabetes Risk ≥ 1/day P for trend

SSB

Age‐adjusted 1.25 (1.11‐1.39) <0.001

Multivariate 1.24 (1.08‐1.35) <0.001

Diet soda

Age‐adjusted 1.91 (1.09‐1.37) <0.001

Multivariate 1.09 (0.98‐1.21) 0.13

De Konning et al. AJCN 2011Adjusted for diabetes risk factors, high TG, HBP, previous weight change, dieting, baseline BMI

Harvard beverage guidelines Red: High sugar, drink sparingly

Yellow: New beverage industry targetNo more than 1 gram sugar/oz 70% less sugar than a typical soft drinkCannot contain calorie‐free sweeteners (no Splenda, Nutrasweet, Stevia, etc.)

Green: Best choice – sugar free or nearly sugar free

http://www.hsph.harvard.edu/nutritionsource/

Healthy beverage recommendations Quit the sugar habit. The average can of sugar‐sweetened soda or fruit punch has 150 calories. If you were to drinks just one can of SSB every day, and not cut back on calories elsewhere, you could gain up to 15 pounds in a year.

Cutting back on sugary drinks can help control your weight and lower risk of diabetes, heart disease, hypertension, and gout.

www.thenutritionsource.org

Healthy beverage recommendations Go calorie‐free naturally. “Diet” drinks with artificial sweeteners may condition our taste buds to crave super‐sweet foods. 

Plain water is the best calorie‐free beverage—but if it’s just too plain, try adding a squeeze of lemon or lime or a splash of 100% fruit juice. 

Un‐sweetened coffee and tea are also healthy calorie‐free choices.

Focus on healthier drinksBeverage manufacturersIndividualsFamily food shoppersFood service (schools, worksites), restaurantsGovernment

AcknowledgementLilian ChuengSari KalinAn PanVasanti MalikLarry DeKoningWalter Willet