Kristina Shkirkova, BSc

Mossavar-Rahmani Y, Kamensky V, Manson JE, Silver B, Rapp SR, Haring B et al. Artificially Sweetened Beverages and Stroke, Coronary Heart Disease, and All-Cause Mortality in the Women’s Health Initiative. Stroke. 2019;50(3):555-562

Consumption of Artificially Sweetened Beverages (ASB) has been associated with cardiovascular disease risks. In a cohort of postmenopausal US women from the Women’s Health Initiative Observational Study authors of the new study examined the association between ASB consumption and incidence of cardiovascular disease, including coronary heart disease, stroke, and mortality.

From among 93,676 women who were part of the Women’s Health Initiative Observational Study (WHI-OS) between 1993 and 1998, the study included 81,714 women, age 50 to 79, who provided information in their estimated ASB consumption. The mean follow-up period of all study participants was 11.9 years from the day of WHI-OS enrollment.

Among study participants, ASB consumption was estimated to be less than one drink a week in 64.1% of women, one to four drinks a week in 19.4%, five to seven in 11.5%, and more than twice a day in 5.1%. Study notes that participants who consumed ASB more than twice a day were younger, more overweight, less active, with past medical history of Diabetes Mellitus (DM), Myocardial Infarction (MI), and strokes compared to participants with lower levels of ASB consumption.

For the outcome analysis authors constructed several multivariate models. Model 1 was unadjusted; Model 2 was adjusted for age, race, and education; Model 3 was adjusted for age, race, education, and health risk variables; Model 4 included all of the Model 3 parameters plus behaviors such as smoking, and alcohol consumption. In all four models, participants who consumed the highest level of ASBs had significantly higher number of fatal and non-fatal ischemic strokes (Hazard Ratio (HR=1.23, 95%CI 1.02-1.47), Coronary Heart Disease (CHD) (HR=1.29, 95%CI 1.06-1.63), and all-cause mortality (HR=1.16, 95%CI 1.07-1.26). However, incidence of hemorrhagic stroke in all four models was not statistically significant between participants with high ASB consumption (i.e. more than two drinks per day) and low ASB consumption.

In a novel finding, his study related consumption of ASB with ischemic stroke subtypes. Authors constructed Cox proportional hazard models for ischemic stroke subtype classes. Higher intake of ASB was associated with higher prevalence of small artery occlusion (SAO) (HR = 1.81, 95%CI 1.18-2.80), but not with large artery atherosclerosis or cardioembolic strokes. These observations were also true in the additional sensitivity analysis where participants with DM and CVD (HR=2.44, 95%CI 1.47-4.04, p=0.001) and hypertension (HR=2.45, w95%CI 1.09-5.50, p=0.03) were excluded.

A key observation of the study was that consumption of two or more ASB a day is associated with all-cause mortality, CHD, and incidence of ischemic stroke of SAO subtype even without mediating effects of DM, CVD and hypertension. Authors conclude that this might indicate a particular pathway of vascular damage induced by ASBs. However, the lack of relationship between ASB consumption and hemorrhagic stroke is not clear.

Although this study only included postmenopausal women, these new findings add to the existing evidence of potentially harmful association between consuming high amounts of artificially sweetened beverages and cardiovascular health. Although this paper does not address sugar sweetened beverages, it might be practical from the public health perspective to propose policies that limit the widespread advertising of sweetened beverages but instead encourage low-sugar or unsweetened beverage substitutions.