Regularly drinking sugar-sweetened beverages was associated with a significantly increased incidence of liver cancer and death from chronic liver disease, according to a prospective cohort study involving nearly 100,000 postmenopausal women.
Compared with consuming three or fewer sugar-sweetened beverages a month, women who drank at least one of these beverages per day had significantly higher rates of liver cancer (18.0 vs 10.3 per 100,000 person-years; adjusted HR 1.85, 95% CI 1.16-2.96, P=0.01), reported Xuehong Zhang, MBBS, ScD, of Brigham and Women’s Hospital and Harvard Medical School in Boston, and colleagues.
This was also true for chronic liver disease mortality (17.7 vs 7.1 per 100,000 person-years; aHR 1.68, 95% CI 1.03-2.75, P=0.04), they noted in JAMA.
However, results differed for artificially sweetened beverages, the authors said.
Compared with the consumption of three or fewer artificially sweetened beverages per month, women who consumed at least one of these beverages a day did not have significantly increased incidence of liver cancer (11.8 vs 10.2 per 100,000 person-years; aHR 1.17, 95% CI 0.70-1.94, P=0.55) or chronic liver disease mortality (7.1 vs 5.3, respectively; HR 0.95, 95% CI 0.49-1.84, P=0.88).
“Even though sugar-sweetened beverage intake has declined steadily in the U.S. from 2003 through 2018, the overall intake remains high, with 65.3% of white adults who reported consuming at least some sugar-sweetened beverages on a given day in 2017-2018,” Zhang and co-author Longgang Zhao, PhD, of the University of South Carolina in Columbia, told MedPage Today in an email.
“Our findings suggest sugar-sweetened beverages as a potential modifiable risk factor for liver cancer and chronic liver disease mortality,” they added. “If our findings are confirmed, reducing sugar-sweetened beverage consumption might serve as a public health strategy to reduce liver disease burden.”
Replacing one serving per day of sugar-sweetened beverages with one serving of coffee or tea was associated with a nonsignificant lower incidence of liver cancer, the authors noted, suggesting that this replacement “might lower the risk of liver cancer and chronic disease mortality.”
For this study, Zhang and team used data from 98,786 postmenopausal women ages 50 to 79 enrolled in the Women’s Health Initiative from 1993 to 1998 at 40 clinical centers in the U.S. They were followed until March 2020.
Beverage intake was assessed using a food frequency questionnaire administered at baseline and defined as the sum of regular soft drinks and fruit drinks (not including fruit juice). Artificially sweetened beverage intake was measured at 3-year follow-up.
Women in this study who consumed more sugar-sweetened beverages were younger (median age 60 for highest consumption vs 63 for lowest consumption) and less physically active, had a lower education level, a higher body mass index (BMI), a lower modified Alternative Healthy Eating Index (AHEI) score, and a higher total energy intake. Higher proportions of women in this group were Black, and never drank alcohol.
Women who consumed more artificially sweetened beverages were younger (median age 60 for highest consumption vs 64 for lowest consumption), had a higher BMI, and a lower modified AHEI score.
At baseline, 6.8% of women consumed one or more sugar-sweetened beverages per day, and 13.1% consumed one or more artificially sweetened beverages per day at 3-year follow-up.
During a median 20.9 years of follow-up, 207 women developed liver cancer and 148 died from chronic liver disease.
While the study was not designed to evaluate the biologic pathways through which sugar-sweetened beverage consumption was associated with adverse liver outcomes, Zhang and team suggested some possible interactions underlying the association.
For example, drinks with high sugar concentrations influence obesity, which is a strong risk factor for liver diseases. “However, adjustments for body mass index did not alter the estimates materially in our study,” Zhang and Zhao said.
They also pointed out that a high consumption of sweetened beverages leads to rapid increases in blood glucose, which further results in insulin resistance — another risk factor for liver cancer and liver diseases.
“Metabolomics studies also reported that sugar-sweetened beverage-associated metabolites such as taurine and phenylalanine were associated with risk of liver cancer,” Zhang and Zhao noted. Furthermore, liquid-added sugar in sugar-sweetened beverages is rapidly absorbed, “which might lead to metabolic conditions and liver problems.”
The authors acknowledged several limitations to their study, including the fact that the food frequency questionnaire was limited to only two questions on sugar-sweetened beverage consumption (regular soft drinks and fruit drinks), and one question on artificially sweetened beverage intake. Moreover, they said they were unable to quantify the subtypes of sugar-sweetened or artificially sweetened drinks, such as sports drinks.