And the data highlights the difference between developed and developing regions of the world.
The case count in Sub-Saharan Africa is ‘particularly sobering’, where sugar-sweetened beverages contributed to more than 21% of all new diabetes cases (meanwhile, in Latin America and the Caribbean, they contributed to nearly 24% of new diabetes cases and more than 11% of new cases of cardiovascular disease).
Publishing their study in Nature Medicine this week, researchers from Tufts University in the US call for ‘urgent, evidence-based interventions’ to cut sugary drink consumption.
Global health burden
The study looked at data from 184 countries between 1990 and 2020.
It defined a sugar-sweetened beverage as any with added sugars and ≥50 kcal per 8oz serving, including soft drinks, energy drinks, fruit drinks, punch, lemonade and aguas frescas (this definition excluded 100% fruit and vegetable juice, diet drinks and sweetened milk).
Researchers estimate that 2.2 million new cases of type 2 diabetes and 1.2 million new cases of cardiovascular disease occur each year globally due to consumption of sugar-sweetened beverages.
That equates to around about 1 in 10 new type 2 diabetes cases, and 1 in 30 new cardiovascular disease cases.
While sugar-sweetened beverages have long been associated with type 2 diabetes and cardiovascular diseases, assessments of the global burden have been hard to come by.
But the researchers say the real value of their work is that it shows the countries and subpopulations most affected by SSB consumption.
For example, adults globally consumed an average of 2.68 oz (248 g) servings per week. But this ranged regionally from 0.7 servings in South Asia to 7.3 servings in Latin America and the Caribbean.
India, China and Bangladesh have relatively low consumption, at around 0.2 servings a week. But Colombians consume 17.4 servings a week.
Men were shown to have ‘modestly higher’ intake than women. But by age, younger people consumed more sugary drinks than older ages across all world regions, although with variations between regions.
How do sugary drinks affect type 2 diabetes and cardiovascular risk?
For a start, sugar-sweetened beverages can be rapidly consumed and digested, meaning that large quantities (and high numbers of calories) can be drunk without feeling full.
High doses of rapidly digested glucose also activate insulin and other regulatory pathways, which can result in visceral fat production, hepatic and skeletal muscle insulin resistance and weight gain.
High doses of rapidly digested fructose directly activate hepatic fat synthesis, leading to ectopic fat deposition and metabolic dysfunction in liver and muscle.
SSBs may also replace other healthier foods in the diet, contributing to harms through their absence.
Excess adiposity (total fat stored in the body) and metabolic dysfunction activate inflammatory cytokines and increase risk of hypertension, dyslipidemia and diabetes.
All these risk factors accelerate atherosclerosis and plaque instability, contributing to ischemic cardiovascular events.
What the researchers highlight is the trajectory of sugar-drink consumption in developing countries where income is rising – and sugary drinks become more accessible and desirable.
Regionally, sub-Saharan Africa experienced the largest increases in SSB-attributable burdens between 1990 and 2020, where substantial increases of SSB intakes correlated with cardiometabolic disease rates.
“Our findings provide a clarion call that the ‘nutrition transition’ from traditional toward Western diets has already occurred in much of the region, requiring urgent policy and public health attention,” explain the researchers.
“As SSB intakes have leveled or started to decline in high-income nations, the beverage industry has turned to emerging markets where populations are highly susceptible to marketing appeal of aspirational ‘Western’ lifestyles.
“Critically, we found in many such regions that SSB-attributable heath burdens are now largest among more educated adults, in line with regional economic growth and burgeoning middle classes. In South Africa, for example, SSB advertising is mainly directed at wealthy males under 45 years old, who also show the highest SSB consumption in the country.”
| Country | SSB servings (8oz) per week |
|---|---|
| Colombia | 17.4 |
| Mexico | 8.5 |
| South Africa | 9.6 |
| Ethiopia | 6.9 |
| Argentina | 5.6 |
| US | 4.9 |
| Nigeria | 4.6 |
Conversely, slowly decreasing consumption of SSBs in Latin America and the Caribbean correlate with modest decreases in SSB-related cardiometabolic burdens, according to the study.
“Nations in this region have implemented several policy efforts targeting SSBs, including taxes, marketing regulations, front-of-package warnings and education campaigns,” note the researchers.
“Yet, SSB-attributable health burdens remain high in the region, and absolute burdens per million adults continue to rise owing to continuing increased rates in obesity, T2D and CVD. While declining SSB intake may have slowed regional growth in obesity, SSB intake remains high, while other risks such as high refined grain intake and physical inactivity remain prevalent. Given the lag between obesity and development of T2D and CVD, as well as the persistent impact of early life influences on later cardiometabolic risk, concerted multigenerational efforts over many years may be needed to reverse these challenges.”
Another key difference between developing and emerging markets and developed countries are the efforts to tackle sugary-drink consumption.
Efforts are not as strong in developing countries: that’s in part due to a lack of data (which is not recorded and tracked in the same way as developed countries, making it hard to create meaningful interventions) and industry opposition.
South Africa became the first sub-Saharan country to introduce a sugar tax in 2018. Prior research - published in 2021 - says the tax has prompted reductions in purchases of sugary beverage volumes.
But the Tufts study also says the beverage industry has simply increased advertising spend to offset negative effects on sales.
Caution advised by beverage industry
The International Council of Beverages Association (ICBA), however, advises caution when looking at the figures produced by the study: primarily because of the data used to create the estimates.
ICBA Executive Director Katherine Loatman said: “Our beverage companies are committed to promoting healthy diets and have concerns about the limitations of this study.
“Accurately estimating consumption or attributing health outcomes to specific foods or beverages in isolation is nearly impossible given the lack of robust data on diets around the world and without consideration of other factors impacting health.
“Effective public policies must be built on a strong scientific foundation; without accurate data, efforts to improve public health risk being ineffective or counterproductive. We know that too much sugar is not good for anyone; that’s why our industry is dedicated to reducing sugar in beverages by offering more choices with less or zero sugar and collaborating with governments and meaningful partners worldwide to address health and nutrition challenges.”
The British Soft Drinks Association (BSDA), meanwhile, points to the efforts that manufacturers have made in developed countries to reduce sugar consumption from beverages.
“All soft drinks are safe to consume as part of a balanced diet,” said a spokesperson.
“The soft drinks sector is full of innovation, offering consumers the widest possible choice of products to enjoy. In 2023, more than seven out of every 10 soft drinks sold in the UK was low or no sugar while between March 2014 and March 2020, take home sugar from soft drinks fell by 43.5%.”
How to tackle high levels of sugary drink consumption - and associated health burdens?
The authors of the Tufts study call for a multi-pronged approach to tackle sugary drink consumption: including public health campaigns, regulation of sugary drink advertising, and taxes on sugar-sweetened beverages.
Some countries have already taken steps in this direction. In fact, 108 national sugar-sweetened beverage taxes are now in effect around the globe, according to data from the WHO.
That includes taxes in Mexico (traditionally a very high consumer of sugary beverages, with a tax introduced in 2014) and the UK, as well as several jurisdictions in the US.
But one thing that both supporters and opposition to sugar taxes can agree on is that there’s no silver bullet when it comes to reducing sugar consumption.
A study, published by researchers from Virginia Tech last year, highlighted that sugar taxes should be accompanied by strong healthy eating guidelines so that people know what to drink in place of sugary beverages.
Their study looked 93 taxes on sugar-sweetened beverages, looking not only at the taxes themselves but the positive health messages promoted alongside them.
