Sugary Drinks an Increasing Threat to Global Cardiometabolic Health

Consumption of added sugar—particularly in sweetened beverages—is a growing problem around the world, and action is needed to halt the trend before diets in many countries become as sugar-laden as those in high-income nations like the United States, researchers argue.

Take Home: Sugary Drinks an Increasing Threat to Global Cardiometabolic Health

Evidence linking added sugars to weight gain, diabetes, and other cardiometabolic issues provides the impetus for developing policies to address these concerns, Barry Popkin, PhD, of the University of North Carolina at Chapel Hill, and Corinna Hawkes, PhD, of City University London (London, England), say in a “personal view” published online December 1, 2015, in The Lancet Diabetes & Endocrinology.

“WHO [World Health Organization], major scientific bodies, and most countries recognize the importance of reducing consumption of sugar-sweetened beverages to improve public health,” they write. “The evaluation of not only sugar taxes, but also new marketing controls and front-of-pack labeling, is important and represents one of the next frontiers—namely, can these policies effectively reduce consumption of sugar-sweetened beverages and intake of total added sugars?”

Added sugar in the food supply is a major problem in developed, high-income countries like the United States, United Kingdom, and Australia. A look at a nationally representative sample of American households in 2013, for example, shows that 74% of products purchased contained caloric and low-calorie sweeteners, 68% contained caloric sweeteners alone, and only 5% contained low-calorie sweeteners.

“We believe that in the absence of intervention, the rest of the world will move towards this pervasiveness of added sugars in the food supply,” Popkin and Hawkes write.

They analyzed worldwide sales of sugar-sweetened beverages and found that the 4 regions with the highest levels were Latin America, North America, Australasia, and western Europe. The latter 3 regions showed declines from 2009 to 2014, but sales increased during the same time period for all other parts of the world. Growth was fastest in low- and middle-income countries in Latin America, the Caribbean, Africa, the Middle East, Asia, and Oceania, with Chile outpacing all other nations.

Taxation Effective

Policies are required both to stem the rapid increase in sugar-sweetened beverage consumption and to reduce intake in areas with already-high levels, Popkin and Hawkes say.

Based on the cardiometabolic risks associated with eating or drinking too much added sugar, WHO has “urged the reduction of added-sugar intake to less than 10% of total energy intake (strong recommendation), and a further reduction to below 5% of total energy intake (conditional recommendation),” with some countries and medical associations recommending the lower limit.

Various strategies have been employed to cut consumption of sugary foods and drinks, including taxation, reduced availability in schools, restricted marketing of such products to children, public awareness campaigns, and both positive and negative labeling. Those attempts have been made mostly in high-income countries, which “suggests that more policy actions are needed beyond high-income countries where rates of consumption are rising,” the authors say.

Popkin told TCTMD in an email that the best option to reduce consumption of added sugar “is to tax sugar-sweetened beverages at 20% or higher as an excise tax. After that, stopping all marketing in all media for sugar-sweetened beverages is second in effectiveness.”

There is evidence suggesting that taxation has been effective in Mexico, Hungary, and France, but further research is need to assess the effectiveness of taxation and other strategies in other parts of the world, Popkin and Hawkes write.

Remaining Questions

Uncertainty about the relationships between consuming either 100% fruit juice or low-calorie sweeteners—both of which could potentially be considered substitutes for sugar-sweetened beverages—and cardiometabolic risks presents a challenge for policy makers, the authors write.

Some research indicates that drinking too much 100% fruit juice can have adverse effects similar to those associated with consuming too many sugar-sweetened beverages. However, there have been no randomized controlled trials addressing the issue, Popkin noted.

There is also no consensus on whether low-calorie sweeteners like saccharin and aspartame have detrimental cardiometabolic effects.

“From a public health perspective, unsweetened or very lightly sweetened water, milk, tea, and coffee are appropriate substitutes, depending on context and age group, although policy makers still need to make practical decisions about how to treat drinks with low-calorie sweeteners and fruit juices in the design of policies to tackle consumption of sugar-sweetened beverages,” Popkin and Hawkes write.


Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol. 2015;Epub ahead of print.

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Todd Neale is the Associate News Editor for TCTMD and a Senior Medical Journalist. He got his start in journalism at …

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  • Hawkes and Popkin report no relevant conflicts of interest.