The burden of cardiovascular disease in adolescents in China and globally due to sugar-sweetened beverage consumption from 1990 to 2021: results from the global burden of disease study 2021

Abstract

Objective

This study aims to analyze the cardiovascular disease (CVD) burden attributable to sugar-sweetened beverage (SSB) consumption among young people worldwide and in China from 1990—2021,in order to provide reference data for strengthening the prevention and treatment of CVD among the general youth population.

Method

2021 Global Burden of Disease (GBD2021) data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. Based on theGBD2021database, data on the CVD burden attributable to SSB consumption among young people worldwide and in China from 1990 to 2021 were collected. The data were analyzed via R 4.3.3 software, and descriptive analysis was conducted via indicators such as the number of deaths, age-standardized mortality rate (ASMR), disability-adjusted life years (DALYs), age-standardized DALY rate (ASDR), and estimated annual percentage change (EAPC). Counts and age-standardised rates were calculated globally, for seven super-regions, 21 regions, 204 countries and territories (including 21 countries with subnational locations), and 811 subnational locations, from 1990 to 2021.

Results

Compared to 1990, the number of CVD deaths among young people attributable to high SSB consumption increased both globally and in China in 2021. However, the global ASMR has decreased, whereas China’s ASMR has increased. The global ASMR decreased from 0.249 (0.044–0.441)/100,000 individuals to 0.17 (0.024–0.313)/100,000 individuals, and China’s ASMR increased from 0.039 (0.01–0.071)/100,000 individuals to 0.12 (0.027–0.215)/100,000 individuals. The global DALY count rose, but the ASDR fell, whereas in China, both the DALY count and the ASDR changed consistently. Between 1990 and 2021, there were variations in mortality rates from CVDs attributed to high SSB intake. Notably, stroke mortality rates increased significantly, whereas ischemic heart disease mortality rates decreased significantly. An analysis of health inequalities indicated that the burden of CVDs due to SSB intake was primarily concentrated in countries with higher sociodemographic index (SDI) levels. However, there was a declining trend in the concentration index in 2021, suggesting an increasing disease burden in countries with lower SDI levels. In 1990, the slope index of mortality relative to the SDI was 2, which decreased to 1.2 in 2021. This finding indicates that with societal development, the disease burden in countries with higher economic levels has increased, whereas the burden in countries with lower economic levels has decreased (According to World Bank classifications, China transitioned from a lower-middle-income economy in 1990 to an upper-middle-income economy by 2021, with its per capita GNI increasing from $310 to $12,850).

Conclusion

This study reveals a pronounced disparity in the burden of SSB-attributable cardiovascular disease among youth aged 15—39 years, with China experiencing a worsening trend in sharp contrast to the overall global decline. To avert a potential youth CVD crisis, it is imperative that economic transformation in China is accompanied by comprehensive preventive health policies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-24160-7.

Introduction

Cardiovascular disease (CVD) remains the leading cause of mortality and disability worldwide, representing a persistent threat to public health. Hypertension and type 2 diabetes are recognized as major contributing factors to CVD development [1]. Extensive research has established that excessive sugar intake—particularly from sugar-sweetened beverages (SSBs)—significantly elevates the risk of hypertension and type 2 diabetes, potentially through mechanisms involving increased body mass index, waist circumference, visceral adiposity, inflammation, β-cell dysfunction, and insulin resistance [2, 3]. However, most of these findings are based on data from middle-aged and older adults [4]. Of particular concern is the continuous global increase in SSB consumption over recent decades, with the most prominent rise observed among adolescents. This trend has raised significant public health concerns regarding the potential for excessive SSB intake to accelerate the onset of metabolic and cardiovascular diseases in younger populations, highlighting the urgent need for preventive strategies targeting youth.

SSBs are nonalcoholic drinks typically composed of water and sugar, often in the form of high-fructose corn syrup or sucrose with added flavoring agents, and they usually contain caffeine. Over the past 30 years, the consumption of SSBs has steadily increased across various populations both globally and in China, particularly among young people in the United States (aged 19—39), where SSBs contribute 9.3% of the daily caloric intake of men and 8.2% of that of women, nearly exceeding dietary recommendations (For both males and females, added sugars should not exceed 10% of total daily energy intake) [5]. According to a national cross-sectional survey of 1,584 adults aged 18—55 years in Chinese cities, SSB consumption has steadily increased over the past 20 years, coinciding with the rapid westernization of dietary patterns in China. In other regions of the world, particularly developing countries, SSB consumption is skyrocketing because of widespread urbanization and beverage marketing strategies [6]. Recent meta-analyses suggest that SSB intake is associated with weight gain, as well as an increased risk of type 2 diabetes and ischemic heart disease [7]. These adverse effects are believed to arise from the rapid elevation of blood glucose leading to endothelial dysfunction, long-term metabolic disturbances such as insulin resistance and dyslipidemia, and the activation of inflammatory pathways, which together contribute to the development and progression of cardiovascular injury [8]. Nevertheless, there is a paucity of research specifically addressing adolescents and young adults, and the precise impact of SSB consumption on the chronic disease burden within these populations remains to be elucidated.

Adolescence is a pivotal period for cardiovascular development and metabolic regulation. During this stage, increased hepatic fructose metabolism in adolescents leads to greater visceral and ectopic fat accumulation. The physiological decline in insulin sensitivity during puberty, combined with SSB-induced insulin resistance, substantially increases the risk of β-cell dysfunction. High SSB consumption in adolescence also triples the risk of early-onset hypertension, and this elevated risk remains into adulthood even if intake decreases later. Importantly, adolescents’ excessive SSB intake arises not only from biological susceptibility but also from factors such as targeted marketing, social network influence, and the widespread availability of SSBs in and around schools. In developing countries like Kenya, similar marketing has caused dramatic increases in adolescent SSB consumption. Meanwhile, traditional healthy beverages are being displaced by sugary drinks, with SSBs now making up over 80% of beverages in school vending machines, further complicating intake control [9].

Given the global and Chinese trends in CVD and SSB consumption, gaining a further understanding of the CVD burden due to SSB intake is crucial for disease control and appropriate healthcare planning. Therefore, we utilized methods and data from the 2021 Global Burden of Disease Study (GBD) to assess the CVD burden due to high SSB intake from 1990 to 2021, both globally and in China. This assessment can assist health departments in developing targeted CVD prevention programs to reduce the consumption of SSBs. The findings of this study will provide direct evidence to support the sugar reduction initiatives under the “Healthy China 2030” strategy, strengthening efforts to address the challenge of the rising prevalence of chronic diseases among younger populations in China.

Methods

Data source

The data used in this study were obtained from the 2021 GBD database (available at https://vizhub.healthdata.org/gbd-results/). The Global Burden of Disease Study covers 204 countries and territories grouped within 7 Super-Regions and 21 regions. Estimates encompass YLL data for 369 diseases/injuries and 87 risk factors. GBD Super Regions constitute a key geographical grouping framework employed within the Global Burden of Disease Study for the analysis and reporting of global health data. These Super Regions are defined and maintained by the Institute for Health Metrics and Evaluation (IHME). Within the hierarchical structure of GBD Super Regions, each Super Region comprises multiple constituent Regions. According to GBD 2021, the global population is categorized into the following seven Super Regions: (1) High-income Asia Pacific; (2) High-income North America; (3) Western Europe; (4) Central Europe, Eastern Europe, and Central Asia; (5) Latin America and Caribbean; (6) North Africa and Middle East; and (7) Sub-Saharan Africa [10]. The global spatial scope is divided into four levels: global, sociodemographic, epidemiological similarity, and individual countries or regions [11]. GBD 2021 data were extracted from vital registration systems, verbal autopsies, censuses, household surveys, disease-specific registries, health service contact data, and other sources. YLDs were calculated by multiplying cause-age-sex-location-year-specific prevalence of sequelae by their respective disability weights, for each disease and injury. YLLs were calculated by multiplying cause-age-sex-location-year-specific deaths by the standard life expectancy at the age that death occurred. DALYs were calculated by summing YLDs and YLLs. For the present study, we extracted data on the burden of CVD attributable to SSB consumption among young people (aged 15—39 years) globally and in China from 1990 to 2021 for analysis.

Inclusion indicators

According to the International Classification of Diseases (ICD) system, CVD attributable to high SSB consumption falls into three main categories: IHD, stroke, and peripheral arterial disease. Stratified by sex and GBD region, in this study, we analyzed the absolute number of deaths, DALYs, and age-standardized rates due to CVD caused by high SSB consumption among global, regional, and Chinese youth populations from 1990 to 2021. DALYs are indicators of health loss and are used as standardized metrics that allow for direct comparisons of disease burdens across different countries, populations, and periods. DALYs represent the sum of YLL due to premature mortality and years lived with disability (YLD). Therefore, in this study, we used age-standardized mortality rates (ASMRs), age-standardized disability-adjusted life-year rates (ASDRs), and estimated annual percentage changes (EAPCs) to describe the CVD burden due to SSB consumption in different regions. Estimates of sugar-sweetened beverage (SSB) intake were derived from the Global Burden of Disease Study 2021 (GBD 2021) through a hierarchical Bayesian meta-regression model (DisMod-MR 2.1). This approach synthesized nationally representative dietary surveys (e.g., NHANES, WHO STEPwise), prospective cohort studies, and retail sales records to generate age-, sex-, and location-specific exposure distributions. Full methodological specifications are detailed in publications by the GBD Risk Factors Collaborators [12].

Age-standardized rates and Uncertainty intervals

The GBD 2021 used population data from the 2012 Revision of the World Population Prospects for Standardization [13, 14]. All mortality and DALY data were directly derived from the point estimates and their corresponding 95% uncertainty intervals (95% UI) officially published in GBD 2021. This UI captures the comprehensive uncertainty arising from model parameters, input data, and computational methodologies, calculated through 1,000 Monte Carlo Markov Chain (MCMC) sampling iterations. Age-standardized rates (ASRs) and their 95% confidence intervals were used to eliminate the impact of variable age distributions across populations and periods, ensuring comparability [15].

Statistical analysis

To calculate and describe the age-standardized rates (ASRs) of deaths and DALYs and the corresponding EAPCs and 95% confidence intervals, we assessed the disease burden and its trends over specific periods. The DALY rate was calculated as the number of cases per 100,000 people. We fitted a linear regression model to the year and the logarithmically transformed ASR, using the slope of the model to calculate the EAPC, which is given by EAPC = (e^^β − 1) × 100%. Here, e is the base of the natural logarithm, and β is the slope of the linear model. We also obtained 95% uncertainty intervals (UIs). The ASR was considered to increase if the lower bound of the 95% UI of the EAPC was greater than 0. Conversely, an ASR was considered to have a decreasing trend if the upper bound of the 95% UI of the EAPC was less than 0. If the 95% UI included both positive and negative values, the ASR was considered stable. All data processing and statistical analyses were performed via R (version 4.3.3).

Statistical analyses of mortality estimates

Cause of death were modelled via the Cause of Death Ensemble model (CODEm). CODEm uses an ensemble of statistical models while also systematically testing combinations of covariates on the basis of their out-of-sample predictive validity. It then combines results to estimate deaths by location, age, sex, and year for a given cause. CODEm was run by sex and separately for countries and territories with and without extensive complete vital registration data to decrease the likelihood of uncertainty inflation from data with high heterogeneity. Multiple iterations of out-of-sample predictive validity for each model were assessed, and models with the smallest root-mean-square error were weighted to generate an ensemble model for a given cause. Other customised modelling strategies were used to estimate deaths for a small group of causes with unique epidemiology, important changes in reporting practices, or a scarcity of data. These modelling strategies included the use of prevalence, incidence, case-fatality data, or data related to sub-causes to inform cause of death estimates.

Data presentation, annual rate of change, uncertainty, and SDI

GBD 2021 metrics were estimated as counts, all-age and age-specific rates per 100 000 population, and age-standardised rates per 100 000 population, calculated using the GBD standard population structure. GBD 2021 present percentage changes over specified time periods (e.g., 1990—2021), and annualised rates of change as the difference in the natural log of the values at the start and end of the time interval divided by the number of years in the interval. All calculations were conducted 500 times to generate draw-level estimates. The number of computations per process was reduced from 1000, as in previous GBD iterations, to 500 for GBD 2021 because simulation testing revealed the final estimates and their uncertainty were not affected by this reduction. Final estimates represent the mean estimate across 500 draws, and 95% uncertainty intervals (UIs) are represented by the 2.5th and 97.5th percentile values across the draws.

Sociodemographic development has been a leading contributor to health gains over the three decades for which GBD has previously tracked changes in burden by location. we also present an analysis of burden for locations across SDI quintiles. SDI is a composite indicator representing the geometric mean of three parameters: the lag-distributed income per capita, average years of schooling, and the fertility rate in females younger than 25 years for a given location. SDI scores were rescaled from 0 (lowest income and years of schooling, and highest fertility) to 100 (highest income and years of schooling, and lowest fertility).

Results

Overview of the CVD burden attributable to SSBs among young people globally and in China from 1990 to 2021

Tables 1 and S2 detail the prevalence of cardiovascular disease across all regions for the years 1990 and 2021, in addition to documenting the estimated annual percentage change (EAPC) spanning from 1990 to 2021, Fig. 1 visualizes the global EAPC.

Table 1.

Global burden of cardiovascular disease attributable to Sugar-Sweetened beverage intake: stratified analysis by sociodemographic index (SDI) for Age-Standardized mortality rate (ASMR) and estimated annual percentage change (EAPC)

Location	Both			Male			Female
	ASMRin1990(95%UI)	ASMRin2021(95%UI)	EAPC,%(95%UI)	ASMRin1990(%95UI)	ASMRin2021(%95UI)	EAPC,%(%95UI)	ASMRin1990(%95UI)	ASMRin2021(%95UI)	EAPC,%(%95UI)
Global	0.25(0.04–0.44)	0.17(0.02–0.31)	−1.60 (−1.67to-1.53)	0.26(0.04–0.49)	0.19(0.02–0.36)	−1.19 (−1.31to-1.06)	0.23(0.05–0.40)	0.15(0.03–0.26)	−1.40 (−1.49to-1.30)
China	0.04(0.01–0.07)	0.12(0.03–0.22)	3.71 (3.51to3.92)	0.04(0.01–0.08)	0.15(0.03–0.27)	4.61 (4.36to4.87)	0.04(0.01–0.07)	0.10(0.03–0.19)	4.19 (3.97to4.41)
SDI
High-middle-SDI	0.32(0.07–0.56)	0.22(0.05–0.39)	−1.21 (−1.30to-1.11)	0.35(0.07–0.63)	0.24(0.04–0.43)	−1.19 (−1.32to-1.07)	0.29(0.08–0.50)	0.20(0.05–0.34)	−1.17 (−1.27to-1.06)
High-SDI	0.37(0.05–0.67)	0.20(0.02–0.36)	−2.69 (−2.86to-2.53)	0.45(0.05–0.85)	0.24(0.020–0.46)	−2.45 (−2.62to-2.27)	0.31(0.06–0.54)	0.15(0.02–0.28)	−2.48 (−2.64to-2.32)
Low-middle-SDI	0.09(0.01–0.17)	0.13(0.01–0.24)	1.10 (1.01to1.19)	0.09(0.01–0.17))	0.14(0.01–0.28))	1.70 (1.60to1.80)	0.08(0.01–0.16)	0.11(0.01–0.21)	1.40 (1.31to1.50)
Low-SDI	0.05 (0.01–0.10)	0.05(0.01–0.10)	0.12(−0.04to0.28)	0.05(0.01–0.10)	0.06(0.01–0.11)	0.53 (0.37to0.70)	0.05(0.01–0.09)	0.05(0.01–0.10)	0.33 (0.17to0.49)
Middle-SDI	0.11(0.01–0.20)	0.15(0.02–0.27)	0.89 (0.81to0.97)	0.12(0.01–0.23)	0.17(0.01–0.33)	1.24 (1.15to1.33)	0.10(0.01–0.17)	0.12(0.02–0.22)	1.07 (0.99to1.16)

ASMR Age-Standardized Mortality Rate (per 100,000 person-years with 95% uncertainty intervals), EAPC Estimated Annual Percentage Change (with 95% uncertainty intervals)

Fig. 1.

Global burden of cardiovascular disease in adolescent populations attributed to high sugar-sweetened beverage intake from 1990—2021

Global

From 1990 to 2021, the number of CVD deaths attributable to SSBs among young people worldwide increased from 81,500 cases to 139,900 cases. The standardized mortality rate decreased from 0.249 per 100,000 individuals to 0.17 per 100,000 individuals, with an EAPC of −1.6% (95% UI = −1.67% to–1.53%). The number of female deaths increased from 42,500 to 68,300 cases, and the number of male deaths increased from 39,000 to 71,500 cases. From 1990 to 2021, the standardized mortality rate due to CVD from SSBs decreased more significantly among females than among males. The female ASMR decreased from 0.229 (0.05–0.398) to 0.147 (0.027–0.264), with an EAPC of −1.4% (95% UI = −1.49% to −1.3%). The male ASMR decreased from 0.265 (0.038–0.49) to 0.192 (0.02–0.359), with an EAPC of −1.19% (95% UI = −1.31% to–1.06%). The global standardized DALY rate decreased from 5.05 (0.528–9.377) in 1990 to 4.147 (0.363–7.811) in 2021, with an EAPC of −1.03% (95% UI = −1.35–0.68%).

China

From 1990 to 2021, the number of CVD deaths attributable to SSBs among young people in China increased from 2,400 cases to 22,600 cases. The standardized mortality rate rose from 0.039 per 100,000 individuals to 0.12 per 100,000 individuals, with an EAPC of 3.71% (95% UI = 3.51–3.92%). The number of female deaths increased from 1,200 to 10,300 cases, and the number of male deaths increased from 1,200 to 12,300 cases. From 1990 to 2021, the standardized mortality rate due to CVD from SSBs increased more significantly among males than among females in China. The female ASMR increased from 0.036 (0.009–0.069) to 0.098 (0.027–0.188), with an EAPC of 4.19% (95% UI = 3.97–4.41%). The male ASMR increased from 0.043 (0.011–0.083) to 0.148 (0.031–0.266), with an EAPC of 4.61% (95% UI = 4.36–4.87%). The standardized DALY rate increased from 0.83 (0.162—1.599) in 1990 to 2.699 (0.576–4.975) in 2021, with an EAPC of 4.37% (95% UI = 4.19–4.56%).

Proportion of CVD attributable to high SSB consumption among the global and Chinese youth populations in 1990 and 2021

The GBD database categorizes CVDs attributable to SSB intake among the youth population into three types: IHD, peripheral arterial vascular disease, and stroke. In Fig. 2, We analyzed the proportion of CVD deaths attributable to high SSB consumption by sex globally, in China, and across 21 global regions. In 1990, at the global level, among males, IHD accounted for 49.3% of deaths, peripheral arterial vascular disease accounted for 2.5%, and stroke accounted for 48.2%; among young females, IHD accounted for 61.2% of deaths, peripheral arterial vascular disease accounted for 2.4%, and stroke accounted for 36.4%. In China, among young males, IHD accounted for 65.9% of deaths, peripheral arterial vascular disease accounted for 0.1%, and stroke accounted for 34%; among young females, IHD accounted for 65.5% of deaths, peripheral arterial vascular disease accounted for 0.1%, and stroke accounted for 34.4%. By 2021, at the global level, among young males, IHD accounted for 43.5% of deaths, peripheral arterial vascular disease accounted for 2.1%, and stroke accounted for 54.4%; among young females, IHD accounted for 56.4% of deaths, peripheral arterial vascular disease accounted for 2.5%, and stroke accounted for 41.1%. In China, among males, IHD accounted for 63.2% of deaths, peripheral arterial vascular disease accounted for 0.2%, and stroke accounted for 36.6%; among females, IHD accounted for 66.9% of deaths, peripheral arterial vascular disease accounted for 0.2%, and stroke accounted for 32.9%.

Fig. 2.

Percentage of cardiovascular disease attributed to high sugar-sweetened beverage intake in global major regions in 1990 and 2021 (%, A: Males; B: Females)

Trends in the prevalence of CVD burdens attributable to SSB consumption among young people worldwide and in China from 1990 to 2021.

From 1990 to 2021, the number of DALYs for CVD attributable to SSB intake continued to rise among the global youth population Fig. 3A, whereas the age-standardized mortality rate (ASMR) remained stable before 1993 and then continuously declined after 1993 Fig. 3C. This indicates that with the improvement of healthcare and the strengthening of preventive measures, the impact of CVD caused by SSBs on the population has decreased. However, in the Chinese youth population, both the ASDR and the number of DALYs associated with CVD rose in tandem Fig. 3B and D, which may be related to changes in socioeconomic, lifestyle, and medical conditions. After 2010, the incidence rate and number of cases of DALYs increased significantly, suggesting that this issue has garnered increased attention and that data collection and diagnostic capabilities have improved. Moreover, the relationship between the mortality rate and the number of deaths due to CVD caused by SSBs follows the same trend as the changes in DALYs, showing a negative correlation globally, but the opposite is true in China, indicating a significant difference in the prevalence trends of SSB-related CVD between China and the rest of the world.

Fig. 3.

Trends in the global and Chinese burdens of cardiovascular disease attributed to high sugar-sweetened beverage intake from 1990—2021. A Changes in global population DALYs; B Changes in Chinese population DALYs; C Changes in global population mortality rates; D Changes in Chinese population mortality rates

Global analysis of health inequality

We used GBD data to conduct a global, cross-national analysis of the all-cause burden of health inequities and to compare the changes in the level of inequity between 1990 and 2021. Health inequities pertain to disparities in health outcomes among populations that are attributable to a multitude of factors.

The concentration index is the ratio of the area between the Lorenz curve and the diagonal to the area under the diagonal (since the area under the diagonal is always equal to 1/2, the concentration index is twice the area between the Lorenz curve and the diagonal). A concentration index closer to 0 indicates a more equitable distribution of health; the further it is from 0, the less equitable the health distribution. Additionally, the concentration index is signed; if the Lorenz curve is above the diagonal, it suggests that the disease burden is concentrated in poorer countries, resulting in a negative index. Conversely, if the Lorenz curve is below the diagonal, the disease burden is concentrated in wealthier countries, yielding a positive index. The results indicate that the CVD burden is predominantly concentrated in countries with a higher sociodemographic index (SDI); however, there was a decreasing trend in the concentration index in 2021. This suggests that the disease burden, which was previously concentrated in developed countries, is gradually diminishing. Although the burden of disease remains relatively high in developed countries, the downward trend in the concentration index signifies a gradual equalization in the global distribution of disease burden Fig. 4A.

Fig. 4.

Health inequality analysis. a Visualization of the concentration index; b Visualization of the slope index

The slope index, which is the slope of the regression line, represents the absolute difference in the predicted values between the highest and lowest groups (absolute inequality). The x-axis represents the relative rank of each point (country), weighted by population, whereas the y-axis represents the CVD mortality rate for each point (country). The determination of relative rank involves several steps: first, all points are sorted from low to high based on their SDI levels; then, each country’s relative rank is determined on the basis of its share of the population. Once the relative rank is established, the slope index is the slope of the regression line of Y (mortality rate) against x (relative rank). The slope index indicates the extent of the association between disease burden and socioeconomic status, ranging from -∞ to +∞. A value of 0 indicates no association between disease burden and socioeconomic status, a positive value indicates a positive correlation, and a negative value indicates a negative correlation. The results indicate that from 1990 to 2021, the burden of CVDs attributable to SSB consumption among young populations globally was positively correlated with socioeconomic status Fig. 4B.

Discussion

In this study, Based on data from the GBD 2021 database, we compared the burden of cardiovascular diseases (CVDs) attributable to sugar-sweetened beverage (SSB) consumption—including ischemic heart disease, peripheral artery disease, and stroke—among young populations in China and globally from 1990 to 2021. Our findings revealed that both the age-standardized mortality rate and the DALY rate for SSB-attributable CVDs have generally declined worldwide over the past three decades. However, in China, these rates have exhibited a clear upward trend, particularly among males. Although the age-standardized mortality rate in China remains below the global average, its persistent rise over the past thirty years—especially among young male populations—has emerged as a significant public health challenge warranting close attention.

A substantial body of epidemiological evidence indicates a strong association between sugar-sweetened beverage (SSB) consumption and elevated cardiovascular disease risk. Multiple meta-analyses and cohort studies consistently demonstrate that individuals with high intake of sugary or artificially sweetened beverages have significantly increased risks of coronary heart disease, stroke, and overall cardiovascular events compared to those with low intake [16, 17]. Notably, subgroup analyses reveal that the association between SSB consumption and cardiovascular diseases, such as hypertension, is more pronounced in Asian populations, which may be related to differences in dietary patterns, genetic background, and beverage types in countries like China. In addition, mechanistic studies have shown that high consumption of industrially sweetened beverages—particularly those rich in fructose—can lead to elevated carotid-femoral pulse wave velocity (CfPWV), as well as increased serum uric acid, triglyceride, and fasting blood glucose levels; these metabolic and vascular changes provide a biological basis for the link between high SSB intake and cardiovascular risk [18–20]. It should be noted that most existing literature focuses on adult populations, with relatively limited research on adolescents, and that residual confounding may persist even after adjusting for factors such as physical activity [21, 22]. Our study extends the current body of evidence by addressing the cardiovascular disease burden related to SSB consumption among adolescents in China, highlighting specific trends within this population and providing new epidemiological and mechanistic insights.

Our further analysis revealed notable differences in the composition and trends of cardiovascular disease burdens attributable to SSB consumption across regions and populations. Globally, ischemic heart disease (IHD) and stroke account for the majority of SSB-related cardiovascular deaths and disabilities. IHD is the leading cause among males, while stroke is more prominent among females. In China, however, stroke remains the predominant outcome for both sexes, which aligns with previous findings indicating a persistently high incidence of stroke across various urban and rural groups [23]. Interestingly, our dual-axis analysis showed that, worldwide, there is typically a negative correlation between the numbers and rates of DALYs and deaths, while in China these relationships are positive. This suggests that the increase in China’s CVD burden is closely tied to rising rates of incidence, likely reflecting unique demographic and health system factors. The stable trend in cardiovascular mortality and DALY rates observed in China from 2005 to 2008 may be related to the implementation of national public health reforms during that period [24].

Socioeconomic differences also play a crucial role in shaping the distribution of SSB-attributable CVD burdens. Although high-SDI countries still account for a larger portion of the global burden, this concentration has declined significantly by 2021, indicating that disease risk is gradually shifting towards low-SDI countries. Studies have shown that households with lower socioeconomic status spend a higher proportion of their income on SSBs [25]. In China, incidence and mortality rates of SSB-related CVD are higher among younger males in more economically developed provinces [26]. The narrowing slope index (from 2.0 in 1990 to 1.2 in 2021) further suggests that differences in disease burden among nations with different economic levels are becoming less pronounced, and the challenge for low-income groups is growing. This trend may be explained by changes in dietary patterns, growing health awareness, and improvement in healthcare resources that have altered the risk landscape.

With rapid economic growth and dietary westernization in China, urban areas have seen a marked increase in the availability and exposure to SSBs, as reflected in the growth of retail outlets and advertising. However, diagnostic capacity for cardiovascular diseases remains uneven, with urban areas having much higher coverage than rural regions, which may lead to underestimation of the true burden of disease [27]. Recent metabolomics studies in rural adolescents have found a high prevalence of early atherosclerosis markers among heavy SSB consumers [28], highlighting the rising health risks faced by underserved populations. Although international interventions, such as SSB taxes, school-based screening, and sugar-equivalent labeling, have shown positive results [29, 30], tailored youth-focused strategies in China remain insufficient.

In summary, SSB-related cardiovascular risk in China has become increasingly complex and dynamic. While the global disease burden is decreasing, there is a clear upward trend among young males and in more developed regions of China. This shift reflects the combined impact of increased SSB exposure, uneven diagnostic coverage, and changing lifestyles. Addressing this public health challenge will require enhanced surveillance, better health education, and innovative policies that target the vulnerabilities of specific regions and populations.

Limitation of the study

This study has several limitations. First, our reliance on the GBD 2021 database, without incorporating hypertension and heart failure in SSB-attributable CVD estimates, may underestimate the total disease burden. The absence of granular subnational data also prevented analysis of regional disparities within China. Second, SSB consumption data, derived from population-based surveys, may not accurately capture individual behaviors, especially for new beverage types or household sharing practices. Third, the use of linear risk functions may overlook threshold or non-linear relationships between SSB intake and CVD risk, and we could not fully account for interactions with other dietary factors or provincial policy variations. Fourth, potential underdiagnosis of early-onset CVD and inconsistent diagnostic coding may bias morbidity and mortality estimates. Finally, the 30-year study period may be insufficient to capture the long-term cardiovascular effects of adolescent SSB consumption manifesting in later adulthood.

Future research directions

Based on the findings of this Global Burden of Disease analysis, future research should prioritize long-term cohort studies among adolescents and young adults, especially in rapidly developing regions like China. Such studies are essential to clarify the causal links between SSB consumption, metabolic biomarkers (e.g., insulin resistance, dyslipidemia), and early-onset cardiovascular disease. It is also imperative to rigorously assess the effectiveness of policy interventions (e.g., taxation, marketing restrictions, and school bans) on SSB consumption and related CVD outcomes across different socioeconomic settings. Future research should further investigate the synergistic effects of SSB intake with other dietary and lifestyle risk factors (such as ultra-processed food intake and physical inactivity), as well as the distinct health impacts of various beverage types and sugar sources. These efforts will support the development of precision interventions and region-specific strategies to address the growing global burden of SSB-related cardiovascular disease in young populations.

Conclusion

This study highlights a significant rise in cardiovascular disease burden among Chinese youths aged 15–39 due to sugar-sweetened beverage consumption, particularly in males, contrasting global declines. Urgent gender-specific interventions, stricter beverage policies, equitable health surveillance, and integrated preventive strategies are needed to address this growing issue.

Abbreviations

GBD

Global burden of disease

CVD

Cardiovascular disease

SSB

Sugar-sweetened beverage

ASMR

Age-standardized mortality rate

ASDR

Age-standardized DALY rate

DALYS

Disability-adjusted life years

EAPC

Estimated annual percentage change

SDI

Sociodemographic index

IHD

Ischemic Heart disease

YLL

Years of life lost

ICD

International classification of diseases

YLD

Years lived with disability

ASR

Age-standardized rates

CfPWV

Carotid‒femoral pulse wave velocity

Authors’ contributions

This study was conceived and designed by Yan-ling Li, Yan-biao Shu, Gang Wang, and Zhi-ling Gao. Yan-ling Li and Ping Xie supervised the research. Statistical analyses were performed by Yan-ling Li, Yan-biao Shu, Weng-bo Zhang and Heng-yu Yan. All authors contributed to the acquisition, analysis, or interpretation of data. Yan-ling Li and Yan-biao Shu drafted the manuscript. All authors have read and approved the final manuscript. Ping Xie served as the guarantor for the study, affirming that all listed authors meet the authorship criteria and that no others meeting the criteria have been omitted.

Funding

This work was support by grants from the National Natural Science Foundation of China (No. 82460051), the Natural Science Foundation of Gansu Province (No. 23JRRA1287), the Research Project on Traditional Chinese Medicine in Gansu Province (No. GZKZ-2021-7).

Data availability

The datasets generated and/or analyzed during the current study are available in the [GBD2021] repository [https://vizhub.healthdata.org/gbd-results/].

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.