Comprehensive review of carbonated soft drink consumption rates and their public health importance

Abstract

Excessive consumption of carbonated soft drinks (CSDs) is associated with significant public health consequences, including increased risk of obesity, type 2 diabetes, cardiovascular diseases, hypertension, and reduced bone mineral density. Daily consumption of sugar-sweetened beverages (SSBs) is linked to a 27% higher risk of type 2 diabetes (RR = 1.27) and a 9% increased risk of cardiovascular disease (RR = 1.09). Each additional daily serving contributes to an average weight gain of 0.42 kg in adults and a 14% higher likelihood of overweight and obesity among adolescents (OR = 1.14). These outcomes arise largely from the high sugar content of CSDs, poor dietary patterns, and displacement of healthier beverages. Risks are particularly pronounced among children, adolescents, and lower-income populations due to targeted marketing, socioeconomic disparities, and increased exposure to unhealthy beverages. CSD consumption has also been linked to psychosocial impacts, including increased risk of depression in women (OR = 1.36) and associations with risky behaviors among adolescents. A range of public health interventions has been introduced to reduce CSD intake. Evidence demonstrates that Mexico’s soda tax reduced purchases by 12% in the first year, while Chile’s restrictions on child-targeted beverage marketing effectively reduced consumption among high-risk groups. School and workplace initiatives promoting healthier beverages also support behavior change. Educational campaigns and broader policy measures continue to influence awareness and consumption patterns. This review synthesizes current evidence on the health consequences of CSD consumption, evaluates the effectiveness of interventions, and highlights research needs, with emphasis on long-term outcomes of CSD alternatives and policy impacts on vulnerable populations.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-26141-2.

Introduction

Excessive consumption of carbonated soft drinks (CSDs) poses a significant public health challenge worldwide, contributing to obesity, type 2 diabetes, cardiovascular diseases, hypertension, dental caries, and reduced bone health. These outcomes are largely driven by the high sugar content of CSDs, their role in displacing healthier beverage options, and their contribution to “empty calories” in the diet. CSDs typically contain water, carbon dioxide (CO₂), sweeteners, flavorings, caffeine, and acids such as citric or phosphoric acid, and are classified as either regular (sugar-sweetened) or diet (artificially sweetened or low-calorie) soft drinks [1, 2]. While diets CSDs are lower in calories, emerging evidence suggests potential metabolic and health risks associated with artificial sweeteners. The popularity of CSDs is reinforced by aggressive marketing strategies targeting children, adolescents, and lower-income populations, as well as their integration into fast-food culture [3, 4].

CSD consumption varies considerably across regions, influenced by cultural preferences, economic development, and public health policies. Developed countries such as the United States, Australia, and parts of Europe historically exhibit high per capita consumption; however, recent declines are observed due to rising health awareness and government interventions such as soda taxes and public campaigns [5, 6]. In contrast, consumption is increasing in developing regions across Africa, Asia, and Latin America, driven by urbanization, economic growth, and the aggressive expansion of global beverage corporations. Socioeconomic status further modulates consumption patterns, with children, adolescents, and lower-income populations experiencing higher exposure to CSDs due to affordability and targeted marketing [7, 8].

The health consequences of CSD consumption extend beyond obesity and metabolic disorders. Regular intake contributes to dental caries and enamel erosion, poor diet quality, and reduced bone mineral density, particularly among adolescents and young adults in critical stages of bone development [9–11]. The growing body of research on these associations has prompted public health authorities worldwide to implement policy interventions, including soda taxes, marketing restrictions, labeling regulations, and school- or workplace-based initiatives, to mitigate the negative impact of CSD consumption [12–14]. Evidence demonstrates that these measures can reduce consumption, especially in high-risk and lower-income populations, although challenges remain in addressing overall dietary patterns and promoting sustained behavioral change.

This review aims to provide a comprehensive analysis of CSD consumption across populations and regions, highlighting key demographic trends. It also examines the public health implications of CSD intake, focusing on obesity, type 2 diabetes, dental health, cardiovascular disease, and bone health. Finally, the review evaluates the effectiveness of public health interventions such as taxation, labeling, marketing restrictions, and educational campaigns. By synthesizing evidence on consumption patterns, health outcomes, and policy measures, this review seeks to inform policymakers, healthcare providers, and the public about strategies to reduce the health risks associated with CSD consumption.

Methodology

This review employed a rigorous literature search strategy to synthesize existing research on the public health implications of CSD consumption. The search was conducted across multiple electronic databases, including PubMed, Scopus, Web of Science, and Google Scholar, to ensure a comprehensive and representative collection of scholarly articles, systematic reviews, and relevant empirical studies. A total of 417 articles were initially identified across these databases, of which 107 met the inclusion criteria and were selected for this review. Figure 1 presents a schematic diagram outlining the search and selection process.

Fig. 1.

A schematic diagram detailing the article search and selection strategy

Search strategy: To maximize relevance and reproducibility, a structured search approach was employed, combining key terms with Boolean operators. An example of the full search string used in PubMed is: (“carbonated soft drinks” OR “soda consumption” OR “sugar-sweetened beverages”) AND (“health effects” OR “obesity” OR “type 2 diabetes” OR “bone health” OR “cardiovascular disease”). Primary search terms, used in various combinations across databases, included “carbonated soft drinks,” “soda consumption,” “health effects of CSDs,” “sugar-sweetened beverages,” “public health,” “obesity and CSD,” “type 2 diabetes and soft drinks,” “dental health and CSDs,” “cardiovascular disease and soft drinks,” “bone health and carbonated drinks,” “soda taxes,” “advertising restrictions on beverages,” and “health promotion and beverage choices.” The search was limited to peer-reviewed articles published in English from January 2000 to 2024. A manual review of reference lists from key articles was also performed to identify additional relevant studies.

Screening and selection: Two independent reviewers screened all identified titles and abstracts for relevance. Full-text articles of potentially eligible studies were then assessed against the inclusion and exclusion criteria. Disagreements between reviewers were resolved through discussion, with consultation from a third reviewer when necessary. Studies were included if they were peer-reviewed, examined the health effects of CSD consumption, focused on population groups such as children, adolescents, or adults, or evaluated public health policies related to CSD intake. Articles were excluded if they were not published in English, did not address CSDs or their health implications, or consisted of opinion pieces, commentaries, or editorials without empirical evidence.

Data extraction: For each included study, the following data were extracted: study details (author, year, country), study design and sample size, population demographics, quantitative outcomes (e.g., relative risks [RR], odds ratios [OR], hazard ratios [HR], and 95% confidence intervals for obesity, type 2 diabetes, cardiovascular disease, dental health, and bone health), and relevant qualitative findings regarding public health interventions.

Quality assessment: The methodological quality and risk of bias of the included studies were systematically evaluated. Cohort and case-control studies were assessed using the Newcastle-Ottawa Scale (NOS), cross-sectional studies were evaluated with the Joanna Briggs Institute (JBI) Critical Appraisal Checklist, and randomized controlled trials were assessed using the Cochrane Risk of Bias tool. Studies were categorized as high, moderate, or low quality, and any discrepancies in scoring were resolved through discussion and consensus between reviewers.

Data Synthesis: Extracted data were narratively synthesized and organized into three thematic areas: (1) Consumption Patterns, including demographic trends (2), Health Effects, encompassing obesity, type 2 diabetes, cardiovascular disease, dental health, and bone health, and (3) Public Health Interventions, including taxation, labeling, and health promotion initiatives.

Consumption patterns of CSDs

Demographics of CSD consumption

Consumption patterns of CSDs differ across various demographic groups, influenced by factors such as age, gender, and socio-economic status. Younger age groups, particularly adolescents and young adults, are the most frequent consumers of CSDs. This demographic is highly targeted by marketing campaigns, and the convenience and social appeal of CSDs make them popular among teenagers and young professionals [15, 16]. Children and adolescents are particularly vulnerable, as their consumption habits are heavily influenced by advertising, peer pressure, and the availability of CSDs in schools and recreational settings. Gender also plays a role in CSD consumption [17, 18]. Research indicates that males tend to consume more CSDs than females across most age groups. This difference may be linked to dietary preferences and habits, as well as the higher caloric needs of males. In addition, males are often more targeted in advertisements for energy and sports drinks, which fall under the broader category of carbonated beverages. However, females, particularly in health-conscious subgroups, may be more likely to choose diet or low-calorie CSD options [19–21].

Socio-economic status significantly influences CSD consumption. Individuals from lower socio-economic backgrounds tend to consume more CSDs compared to those from higher SES groups. This is largely due to the affordability and easy availability of CSDs, which are often cheaper than healthier beverage options like fresh fruit juices or milk. Lower-income households may also be more susceptible to aggressive marketing tactics and are less likely to have access to health education programs that promote healthier dietary choices [22–24].

Taken together, these demographic disparities indicate that high CSD consumption is disproportionately concentrated among younger individuals and lower-SES populations, which may exacerbate existing health inequities. This pattern underscores how socioeconomic vulnerability contributes to differential exposure to unhealthy beverage environments and, consequently, to unequal burdens of diet-related diseases.

Regional variations in CSD consumption

CSD consumption exhibits substantial regional variation, particularly when comparing high-income countries with low- and middle-income countries (LMICs). In high-income regions such as the United States, the United Kingdom, and Australia, per-capita CSD intake remains elevated but has shown a gradual decline over the past decade [25, 26]. This downward trend is largely attributed to heightened public awareness of the adverse health effects of SSBs, coupled with policy interventions including taxation, front-of-package labeling, and restrictions on marketing to children. These settings have also experienced notable shifts toward low-calorie and zero-sugar alternatives, reflecting broader consumer transitions toward healthier beverage choices [27, 28].

In contrast, many LMICs particularly in Latin America, Southeast Asia, and parts of Africa are experiencing rising CSD consumption. This pattern is driven by rapid urbanization, increased disposable income, Westernization of dietary habits, and the aggressive expansion of multinational beverage companies. In these regions, CSDs are increasingly integrated into everyday dietary practices, often in contexts where nutrition education, regulatory mechanisms, and public health interventions remain limited [29–31]. As a result, these countries are undergoing a nutrition transition that mirrors earlier trends in high-income countries but at a faster pace and often with more pronounced health consequences.

Global data corroborate these divergent trajectories. Longitudinal analyses show that worldwide per-capita CSD consumption increased from approximately 36 L in 1997 to 43 L in 2010, with the most substantial growth occurring in LMICs [32]. High-income countries remain among the highest consumers led by the United States, Mexico, and Chile where annual per-capita intake frequently exceeds 150–180 L [32, 33]. More recent market assessments indicate continued expansion of carbonated beverage sales in emerging economies such as India, Indonesia, and Vietnam, while consumption in North America and Western Europe has plateaued or declined [34]. Collectively, these trends demonstrate that global CSD consumption is increasingly driven by growth in developing regions, even as some high-income countries begin to show signs of sustained reduction.

This global shift has important public health implications. Rising intake in LMICs frequently coincides with socioeconomic vulnerabilities, limited access to preventive healthcare, and weaker regulatory structures. Consequently, increased CSD consumption in these settings may exacerbate existing health inequities and intensify the burden of non-communicable diseases, including obesity, type 2 diabetes, and cardiovascular disease.

Influences on CSD consumption

Several factors drive CSD consumption, including marketing, pricing, and accessibility. Aggressive marketing campaigns, particularly those targeting children and adolescents, play a significant role in shaping consumption patterns. CSD companies invest heavily in advertising through television, digital media, sports sponsorships, and celebrity endorsements to make their products appear attractive, trendy, and socially desirable. These campaigns often emphasize lifestyle and social status, making CSDs appealing to younger consumers seeking identity and peer acceptance [35, 36]. In addition, product placement in movies, television programs, and social media further embeds these beverages into popular culture. Pricing is another key factor influencing CSD consumption. Carbonated soft drinks are often less expensive than healthier alternatives, such as bottled water, fresh fruit juices, or milk. This price difference increases their appeal, particularly among lower-income populations. Promotional offers, discounts, and bulk pricing further encourage frequent purchases and habitual consumption. In many countries, the low cost of sugary beverages reflects the lack of soda taxes or other economic disincentives that might otherwise reduce consumption [37, 38].

Accessibility also plays a pivotal role in driving CSD consumption. In most urban and suburban areas, CSDs are readily available in grocery stores, convenience shops, vending machines, and fast food restaurants. Their availability in schools, workplaces, and recreational settings further increases their consumption among children, adolescents, and adults alike [39, 40]. In some countries, access to safe drinking water may be limited, leading to a reliance on packaged beverages like CSDs, even if they are not the healthiest option [39, 41]. Additionally, in certain low-income and developing regions, CSD consumption may be partly driven by structural issues, including limited access to clean and safe drinking water. In such contexts, packaged beverages despite their sugar content may be perceived as safer and more reliable options, further reinforcing the complex socioeconomic drivers of CSD intake.

Together, these demographic, regional, and structural factors highlight not only the multifaceted nature of CSD consumption but also the underlying inequities that shape beverage environments. Addressing these influences is essential for developing effective, context-specific public health interventions.

Nutritional content of CSDs

CSDs, as illustrated in Fig. 2, contain a variety of ingredients that enhance their taste and appeal, while simultaneously raising concerns about their nutritional quality and potential health impacts. One of the most prominent ingredients is sugar, as shown in Table 1, which clearly illustrates the differences in sugar content and caloric load between regular and diet CSDs. Regular CSDs are often high in added sugars, with a single serving containing approximately 20 to 40 g, primarily in the form of high-fructose corn syrup or sucrose [1, 42]. This substantial sugar content leads to a high caloric load without providing essential nutrients, classifying CSDs as “empty calories.” For individuals who regularly consume these beverages, the excess sugar can quickly surpass recommended daily limits, contributing to weight gain, insulin resistance, and a heightened risk of developing type 2 diabetes [10, 27, 43].

Fig. 2.

Commonly consumed carbonated soft drinks

Table 1.

Nutritional content of popular carbonated soft drinks (Per 12 oz/355 ml Serving)

Soft drink	Calories	Sugar content	Artificial Sweeteners	Caffeine content in mg
Coca-Cola (Regular)	140	39	None	34
Pepsi (Regular)	150	41	None	38
Mirinda (Regular)	160	44	None	0
7UP (Regular)	140	38	None	0
Sprite (Regular)	140	38	None	0
Coca-Cola (Diet)	0	0	Aspartame	34
Pepsi (Diet)	0	0	Aspartame	35
Mirinda (Diet)	5	0	Aspartame, Sucrose	0
7UP (Diet)	0	0	Aspartame	0
Sprite (Diet)	0	0	Aspartame	0

For more health-conscious consumers, diet CSDs are formulated with artificial sweeteners like aspartame, sucralose, or saccharin, which provide sweetness without the calories of regular sugar [39]. While these sweeteners significantly reduce the caloric intake from diet beverages, they remain controversial due to potential associations with metabolic changes and an increased appetite for sweet foods, although evidence on these effects remains mixed [44]. In addition to sugars or artificial sweeteners, many CSDs contain caffeine, which acts as a mild stimulant. While caffeine can increase alertness and energy in small doses, its consumption through CSDs, especially among children and adolescents, can contribute to anxiety, sleep disturbances, and dependency [45, 46].

Beyond sugar and caffeine, CSDs often contain phosphoric acid and citric acid, which can influence calcium balance in the body. These acids have implications not only for dental health but also for bone mineral density and cardiovascular health, highlighting additional physiological concerns related to habitual CSD consumption. The caloric contribution of CSDs to an individual’s daily intake is significant. A single can of regular CSD may contain between 140 and 180 calories, which can account for a substantial portion of a person’s recommended daily calorie intake, especially when consumed in large quantities or as part of a diet that includes other high-calorie, low-nutrient foods [47, 48]. For individuals consuming multiple servings per day, CSDs can contribute hundreds of extra calories, potentially leading to excessive weight gain. This contribution to daily caloric intake, particularly from added sugars, is a critical factor driving obesity and related health issues in both developed and developing countries. Thus, while CSDs offer no nutritional benefits, their high sugar content and caloric load make them a major contributor to poor diet quality and chronic health conditions [27, 49].

Health effects of carbonated soft drink consumption

Data quality assessment

The quality of the 30 included studies was systematically assessed using the Newcastle-Ottawa Scale (NOS) for observational studies and the Cochrane Risk of Bias tool or AMSTAR 2 for systematic reviews and meta-analyses. Two independent reviewers performed the assessment, and disagreements were resolved through discussion. Overall, the majority of studies were rated as moderate to high quality, indicating robust evidence for synthesis. High-quality studies included large prospective cohorts and comprehensive meta-analyses, while moderate-quality studies were mainly cross-sectional designs with potential limitations in temporality and confounding control. This evaluation ensures that the conclusions drawn from this review are based on reliable and methodologically sound evidence. A detailed summary of the quality assessment is presented in Table 2.

Table 2.

Data quality assessment of included studies

Author (Year)	Study Design	Population / Sample Size	Quality Assessment Tool	Overall Quality Rating
Garduño-Alanís et al., (2020) [50]	Cross-sectional & longitudinal cohort	9,695 adults (Eastern Europe)	NOS	Moderate
González-Morales et al., (2020) [51]	Prospective cohort	1,000 + health workers	NOS	High
Kim et al., (2021) [52]	Cross-sectional	15,000 adults	NOS	Moderate
Nguyen et al., (2023) [10]	Systematic review & meta-analysis	Multiple cohorts	Cochrane / AMSTAR 2	High
Hu et al., (2023) [53]	Cross-sectional	Adolescents in 107 countries	NOS	Moderate
Rivera-Paredez et al., (2020) [54]	Prospective cohort	2,000 + Mexican adults	NOS	High
Meng et al., (2021) [55]	Systematic review & meta-analysis	Multiple cohorts	Cochrane / AMSTAR 2	High
Li et al., (2023) [56]	Meta-analysis	Multiple cohorts	Cochrane / AMSTAR 2	High
Lin et al., (2022) [57]	Prospective cohort	494 children (Taiwan)	NOS	Moderate
Pacheco et al., (2020) [58]	Prospective cohort	106,178 women	NOS	High
Kim et al., (2021) [59]	Cross-sectional	3,705 men (Korea)	NOS	Moderate
Meng et al., (2023) [55]	Prospective cohort	3,828 adults	NOS	High
Hernández-López et al., (2022) [60]	Prospective cohort	5,000 + adults	NOS	High
Chen et al., (2020) [11]	Prospective cohort	2,500 adults	NOS	High
Kim & Yoo, (2020) [61]	Cross-sectional	2,499 adolescents & young adults	NOS	Moderate
Bragança et al., (2023) [62]	Cross-sectional	6,620 young adults	NOS	Moderate
Ahn & Park, (2021) [63]	Systematic review & meta-analysis	Multiple cohorts	Cochrane / AMSTAR 2	High
Pan et al., (2021) [64]	Systematic review & meta-analysis	Multiple cohorts	Cochrane / AMSTAR 2	High
Zhang et al., (2021) [65]	Prospective cohort	2,888 adults	NOS	High
Khan et al., (2021) [66]	Cross-sectional	36,173 adolescents	NOS	Moderate
Liu et al., (2022) [67]	Cross-sectional	175,261 adolescents	NOS	Moderate
Narita et al., (2024) [68]	Prospective cohort	94,873 adults	NOS	High
Inchingolo et al., (2023) [69]	Systematic review	Multiple cohorts	Cochrane / AMSTAR 2	High
Lutovac et al., (2017) [70]	Cross-sectional	500 children	NOS	Moderate
Moynihan, (2016) [71]	Review article	Multiple populations	AMSTAR 2	Moderate
Vasireddy et al., (2021) [72]	Cross-sectional	1,200 adults	NOS	Moderate
Tahmassebi & BaniHani, (2020) [48]	Review article	Multiple populations	AMSTAR 2	High
Pietrantoni & Mayrovitz, (2022) [73]	Review	Multiple populations	AMSTAR 2	Moderate
Farhangi et al., (2020) [74]	Meta-analysis	Multiple cohorts	Cochrane / AMSTAR 2	High
Das & Ingole, (2023) [75]	Prospective cohort	2,500 adults	NOS	High

Overview of health risks associated with CSD consumption

Consumption of CSDs is associated with a range of adverse health outcomes, quantified through numerous epidemiological studies. Key findings include a 27% increased risk of type 2 diabetes per additional daily serving of SSBs, a 4.69-fold increased risk of fractures among daily CSD consumers, elevated risks of obesity, hypertension, cardiovascular disease, dental erosion, and metabolic complications such as non-alcoholic fatty liver disease (NAFLD). Mental and behavioral health effects, including depression, sleep disturbances, and suicidality, have also been reported in adolescent populations. This overview contextualizes the detailed relative risks and outcomes discussed in subsequent subsections.

Obesity and weight gain

The rising consumption of CSDs has been strongly linked to increasing obesity rates globally, particularly among children and adolescents. Recent global health statistics show alarming trends, with the World Health Organization (WHO) reporting that in 2022, over 390 million children and adolescents aged 5–19 were classified as overweight or obese [76]. This surge coincides with the growing availability and aggressive marketing of CSDs, which are often portrayed as fun and appealing to younger consumers. These beverages, high in added sugars, contribute significantly to excessive caloric intake, offering minimal to no nutritional benefits [10, 27].

In a study conducted in Eastern Europe (HAPIEE study), among adult cohorts from the Czech Republic, Russia, and Poland, the consumption of SSBs was found to be positively associated with higher body mass index (BMI). Compared to individuals who never consumed SSBs, those who consumed them daily exhibited significantly higher BMI in the Czech cohort (β = 0.28; 95% confidence interval [CI] = 0.02–0.54), Russian cohort (β = 1.38; 95% CI = 0.62–2.15), and Polish cohort (β = 0.83; 95% CI = 0.29–1.37) populations. Additionally, occasional and daily consumption of artificially‑sweetened beverages (ASBs) was also correlated with BMI increases across these three country cohorts. Interestingly, the association between fruit juice intake and BMI varied by population: Russian participants showed a positive association (β = 0.75; 95% CI = 0.28–1.21), while a negative trend was observed among Czech participants (β = −0.42; 95% CI = − 0.86 to 0.02). Furthermore, among the Russian cohort, participants who consumed either SSBs or ASBs experienced a notable BMI increase over the study’s follow‑up period, underscoring the persistent influence of sugary and artificially sweetened beverages on body weight [50].

Furthermore, several studies have demonstrated that regular consumption of CSDs is associated with weight gain and obesity-related complications. For instance, a study reported that a daily increase in soft drink consumption corresponded to an average weight gain of 0.10 kg per year (95% CI: 0.00–0.19), independent of leisure-time physical activity. Individuals meeting WHO physical activity recommendations gained 0.36 kg per additional daily serving, while those less active gained 0.48 kg per year, indicating that physical activity, although beneficial, does not fully counteract the impact of CSD consumption on weight gain [51].

Beyond weight gain, CSD consumption has been linked to adverse nutritional and mental health outcomes. Adults who consumed soft drinks exhibited higher total energy intake and fat density but lower nutrient densities of carbohydrates, dietary fiber, and key micronutrients. Gender-specific differences were observed: in men, soft drink intake was associated with a reduced risk of depression, whereas women showed increased risks of depression (OR = 1.36; 95% CI = 1.12–1.64), obesity (OR = 1.42; 95% CI = 1.12–1.81), and poor subjective health status [59].

A systematic review and meta-analysis further confirmed the link between SSB consumption and weight gain across age groups. Each additional daily serving of SSBs was associated with a BMI increase of 0.07 kg/m² in children and a weight gain of 0.42 kg in adults. Interventions to reduce SSB intake resulted in BMI reductions of − 0.21 kg/m² in children and − 0.49 kg in adults, whereas adding SSBs led to an average adult weight gain of 0.83 kg. The review also reported a clear dose–response relationship between SSB consumption and weight gain, underscoring the importance of reducing intake to mitigate obesity risk [10].

Large-scale global studies further highlight these associations. A study involving 405,528 school-going adolescents from 107 countries and regions (mean age 14.2 years, 48.4% males) found that daily soft drink consumption was positively correlated with overweight and obesity prevalence (R = 0.44; P < 0.001). Daily consumers had a 14% higher likelihood of being overweight or obese (OR = 1.14; 95% CI = 1.08–1.21) [53]. In addition, excessive CSD consumption also contributes to metabolic dysfunction. High sugar intake from CSDs promotes fat accumulation, particularly visceral fat, increasing the risk of insulin resistance, type 2 diabetes, and other metabolic complications. These effects are observed across age groups, from children to adults, highlighting the broad public health implications of regular CSD consumption [49, 77, 78].

Type 2 diabetes and insulin resistance

The consumption of CSDs has been consistently associated with an elevated risk of developing type 2 diabetes (T2D) and insulin resistance. Epidemiological studies indicate that individuals who consume high amounts of sugary beverages, including CSDs, are more likely to experience impaired glucose tolerance and reduced insulin sensitivity [79]. This is particularly concerning given that the WHO estimates over 422 million people worldwide are living with diabetes, with incidence rates continuing to rise [80].

Longitudinal cohort studies provide further evidence of this association. In a study of 1,073 adults followed over a mean period of 6.7 years, participants had a mean baseline age of 44 years (SD = 11.4), and 47% had attained a high educational level. Cumulative soft drink consumption averaged 1,022.7 servings (SD = 1,277.7), or approximately 0.42 servings per day, while diet soda and flavored water consumption averaged 175.9 and 2,651.5 servings per year, respectively. Over the follow-up period, median HOMA-IR increased from 1.6 to 2.1, the prevalence of overweight individuals rose from 42.3% to 44.3%, and obesity prevalence increased from 15.4% to 19.0%. Each additional daily serving of CSDs was associated with a 0.05 unit increase in HOMA-IR per year (95% CI: 0.01–0.08), highlighting the cumulative impact of CSD consumption on insulin resistance. These findings emphasize that both age and education level may influence consumption patterns and metabolic outcomes [54].

Systematic reviews and meta-analyses reinforce these associations. For each additional daily serving of SSBs, the risk of developing T2D increased by 27% (RR: 1.27, 95% CI: 1.15–1.41), whereas each serving of ASBs was associated with a 13% increased risk (RR: 1.13, 95% CI: 1.03–1.25). Daily SSB consumption was also linked to a 9% higher risk of cardiovascular diseases (RR: 1.09, 95% CI: 1.07–1.12), and ASBs to an 8% increase (RR: 1.08, 95% CI: 1.04–1.11). Linear relationships were observed between SSB consumption and both T2D and CVDs, while ASBs showed non-linear relationships for these outcomes [2].

A more recent meta-analysis confirmed these trends and provided demographic-specific insights. Among adult populations, SSB intake was associated with a relative risk of 1.27 for T2D (95% CI: 1.17–1.38), whereas ASBs were linked to a risk of 1.32 (95% CI: 1.11–1.56). Fruit juice consumption did not show a significant association (RR: 0.98; 95% CI: 0.93–1.03). Higher intakes of SSBs and ASBs were also positively associated with hypertension, stroke, and all-cause mortality (RRs ranging from 1.08 to 1.54), highlighting the broad cardiometabolic impact of these beverages [56].

Mechanistic explanations underscore these epidemiological findings. The high sugar content in CSDs induces frequent spikes in blood glucose, prompting increased insulin secretion. Over time, this persistent demand can overwork pancreatic beta cells, resulting in insulin resistance and heightened T2D risk. This effect is particularly pronounced in population groups with limited access to healthcare, low nutritional literacy, and higher exposure to aggressive marketing of CSDs. Additionally, the growing consumption of artificially sweetened diet sodas, often perceived as healthier alternatives, may further complicate risk patterns in certain demographic groups [81–83].

Dental health

The consumption of CSDs has a significant impact on dental health, particularly concerning dental erosion and cavities. The high sugar content in CSDs creates an optimal environment for oral bacteria, which metabolize sugars and produce acids. These acids contribute to demineralization of tooth enamel, increasing susceptibility to cavities. Over time, repeated enamel erosion can lead to serious dental problems, including extensive decay and long-term structural damage [69].

In addition to sugar, many CSDs contain acidic ingredients, such as citric acid and phosphoric acid, which directly erode enamel and exacerbate dental issues. Regular consumption of CSDs has been associated with significant enamel erosion; individuals consuming more than one sugary drink per day are at a higher risk of developing dental caries and overall deterioration of oral health [70]. Children and adolescents are particularly vulnerable, as frequent CSD intake combined with inadequate oral hygiene practices increases the likelihood of tooth decay. Globally, dental caries remains one of the most common chronic diseases, affecting over 2 billion people, with younger populations disproportionately impacted [71, 84].

Socioeconomic factors further influence the oral health impact of CSD consumption. In lower-income communities, limited access to dental care amplifies the consequences of sugary beverage intake, contributing to long-term health disparities. Poor oral health can result in pain, difficulty eating, and impaired speech, negatively affecting quality of life and overall well-being [72]. The rise in CSD consumption over recent decades, particularly among children and adolescents, has been linked to adverse oral and general health outcomes. Many commercially available soft drinks provide energy without essential micronutrients, vitamins, or minerals, compounding their health risks. In response, policy interventions such as banning CSDs in schools, restricting marketing, reformulating beverages, and implementing sugar taxes have been introduced to mitigate these effects [48].

Evidence from longitudinal and observational studies supports these associations. In a cohort of 494 children followed over one year, 117 developed new dental caries in permanent teeth, corresponding to a caries incidence rate of 0.183 per person-year. Children who preferred sugar-rich beverages had a 4.3 times higher risk (95% CI: 1.2–15.7) of developing caries compared to those who preferred non-sugary drinks (P < 0.05). Frequent consumption of handmade sugary drinks was associated with a 1.7 times higher risk (95% CI: 1.1–2.9) [57].

A systematic review examining the effects of CSDs on enamel integrity found that excessive intake of acidic beverages significantly increases the risk of dental erosion, leading to reduced physical and mechanical strength of enamel. This degradation promotes bacterial adhesion, elevating caries risk. Most commercially available CSDs have a pH below the critical threshold for enamel demineralization, and both the acidity level and duration of exposure were shown to influence the degree of enamel damage [69].

Cardiovascular diseases

The consumption of CSDs has been consistently linked to an increased risk of cardiovascular diseases (CVDs), primarily through effects on blood pressure and lipid profiles. High intake of added sugars from CSDs is associated with elevated blood pressure, a major risk factor for heart disease and stroke [73]. A meta-analysis revealed that individuals consuming more than one sugary beverage per day had a significantly higher risk of developing hypertension compared to those with low or no intake [74]. Globally, hypertension affects approximately 1.3 billion people, making it a leading contributor to cardiovascular mortality [85].

CSD consumption also adversely affects lipid profiles, with increases in triglycerides and decreases in high-density lipoprotein (HDL) cholesterol levels. Elevated triglycerides and low HDL cholesterol are strong predictors of atherosclerosis, contributing to plaque buildup in arteries and increasing the risk of heart attacks and strokes [75, 86]. In addition, acidic ingredients and additives commonly found in CSDs, such as phosphoric acid, may lower calcium levels and further influence cardiovascular risk [87].

Prospective cohort studies provide evidence of these associations. In the California Teachers Study, 106,178 women free from CVD and diabetes at baseline were followed for 20 years. Consumption of ≥ 1 serving per day of SSBs including caloric soft drinks, sweetened bottled waters or teas, and fruit drinks was associated with a 19% higher risk of incident CVD (HR, 1.19; 95% CI, 1.06–1.34), a 26% higher risk of revascularization (HR, 1.26; 95% CI, 1.04–1.54), and a 21% higher risk of stroke (HR, 1.21; 95% CI, 1.04–1.41), compared to women who rarely or never consumed SSBs. Fruit drinks and caloric soft drinks were associated with 42% and 23% higher risks of CVD, respectively, highlighting differential effects by beverage type [58].

Sex- and age-specific patterns have also been observed. A cross-sectional study of 3,705 Korean men (aged 30–64 years) from the 2014–2016 KNHANES examined the relationship between SSB consumption and 10-year CVD risk. Men consuming SSBs 3–4 times per week and ≥ 5 times per week had higher adjusted odds ratios for high CVD risk 1.49 (95% CI: 1.05–2.11) and 1.61 (95% CI: 0.97–2.67), respectively compared to those consuming ≤ 2 times per week. Importantly, no association was observed among men who engaged in regular physical activity, indicating that lifestyle factors may modulate risk [52].

Another study examining 3,828 participants (2,007 men and 1,821 women) evaluated the incidence of carotid atherosclerosis via ultrasonography. Over a 3.2-year follow-up, higher soft drink intake was associated with an increased risk of carotid atherosclerosis in women (HR: 1.56, 95% CI: 1.14–2.13), but not in men, suggesting potential sex-specific susceptibility [55].

Longitudinal data also indicate that each additional daily serving of soft drinks is linked to modest but meaningful increases in blood pressure. Over ten years, systolic pressure rose by 2.08 mm Hg (95% CI: 0.21–3.94) and diastolic pressure by 2.09 mm Hg (95% CI: 0.81–3.36). The association with diastolic pressure was stronger among participants with pre-existing hypertension, whereas no significant relationship was found for non-caloric soft drinks [60].

Metabolic complications

Bone health

The consumption of CSDs is increasingly recognized as a risk factor for compromised bone health. Excessive intake of CSDs, particularly cola beverages containing high levels of phosphoric acid, has been associated with reduced bone mineral density (BMD), especially in adolescents and young adults during critical periods of bone development. Phosphoric acid can interfere with calcium absorption, disrupting the calcium-phosphorus balance necessary for maintaining strong bones [11].

Dietary displacement further exacerbates bone health risks. Individuals who consume high quantities of CSDs often replace calcium-rich beverages such as milk and fortified plant-based drinks. This pattern is particularly concerning among adolescents aged 9–18 years, who are in their peak bone-building years. A 7-year follow-up study by Chen et al. (2020) reported that daily soft drink consumers had a 2.72-fold higher odds (95% CI: 1.45–5.09) of experiencing fractures compared to non-consumers, after adjusting for sociodemographic factors, lifestyle, and dietary patterns. Additionally, over a mean follow-up of 5 years with 569 incident fracture cases, daily CSD consumers had a hazard ratio of 4.69 (95% CI: 2.80–7.88) for incident fractures relative to non-consumers, indicating a direct association between frequent CSD intake and fracture risk.

Population-specific evidence supports these findings. In a study of 2,499 Korean adolescents and young adults (12–25 years), participants were classified as cola drinkers or non-cola drinkers based on 24-hour dietary recall. Bone mineral density assessed via dual X-ray absorptiometry revealed that male cola drinkers had 4–5% lower BMD in the whole body, femur, and femoral neck compared to non-drinkers [61]. Both male and female cola drinkers also reported lower frequencies of milk consumption, although calcium intake did not differ significantly between groups, suggesting that beverage choice rather than overall calcium intake may influence BMD.

Mental and behavioral health effects

Adolescent populations are particularly affected by psychosocial and behavioral outcomes associated with CSD consumption. Data from the Global School-Based Student Health Survey (GSHS) covering 36,173 adolescents in Bangladesh, Indonesia, Laos, the Philippines, Thailand, and Timor-Leste revealed that 23.9% reported no CSD intake in the past 30 days, 38.8% consumed CSD less than once per day, 19.9% once per day, and 17.5% two or more times per day. Higher CSD intake was associated with increased odds of being attacked, sustaining injuries, engaging in physical fights, being bullied, school truancy, and substance use, including tobacco, alcohol, cannabis, and amphetamines. Moreover, higher consumption correlated with loneliness, anxiety, suicidal ideation, suicide planning, and attempts [88].

An expanded analysis of 175,261 adolescents (mean age 13.8 years; 48.5% female) from the GSHS examined stress-related sleep disturbances. Adolescents consuming CSDs three or more times per day had over 50% higher odds of reporting sleep disturbances compared to those consuming less than once per day (males: OR = 1.55; 95% CI: 1.42–1.70; females: OR = 1.51; 95% CI: 1.37–1.68). The association was significant across most countries, with some variation in low-income nations and consistent across WHO regions for males but mixed for females [66].

CSD consumption has also been associated with suicidality. Among U.S. adolescents, failure to meet 24-hour movement guidelines combined with high soft drink consumption was linked to higher prevalence of suicidal ideation (OR: 1.69; 95% CI: 1.30–2.19) and suicide planning (OR: 1.76; 95% CI: 1.34–2.33). Consuming CSDs three or more times daily increased the risk of suicidal ideation, planning, attempts, and medically treated attempts, independent of adherence to physical activity, screen time, or sleep duration recommendations [67].

Finally, the relationship between CSD intake and depression has been demonstrated in large cohort studies. A five-year study of 94,873 participants (80,497 completing follow-up) found 18,172 new cases of depression. High consumption of sugary drinks was associated with elevated risk differences (RD) for depression: total sugary drinks (RD: 3.6%; 95% CI: 2.8–4.3), carbonated beverages (RD: 3.5%; 95% CI: 2.1–4.7), vegetable juice (RD: 2.3%; 95% CI: 1.3–3.4), 100% fruit juice (RD: 2.4%; 95% CI: 1.1–3.6), and sweetened coffee (RD: 2.6%; 95% CI: 1.9–3.5). In contrast, black coffee consumption was associated with reduced depression risk (RD: -1.7%; 95% CI: -2.6–-0.7%). Results were consistent across sex, age, and body mass index [68].

Other health consequences

The relationship between CSD consumption and all-cause mortality, CVD mortality, and cancer mortality has been investigated in systematic reviews and meta-analyses. Increasing SSB intake by 250 mL per day was associated with a 4% higher risk of all-cause mortality and an 8% increase in CVD mortality, translating to an additional 5 and 3 death per 1,000 individuals, respectively, though these findings were based on low-certainty evidence. Similarly, an equivalent increase in ASB consumption was linked to a 4% higher risk of all-cause mortality and CVD mortality, corresponding to 5 and 2 additional deaths per 1,000 individuals, also with low certainty. No significant associations were observed between SSBs or ASBs and cancer mortality, although linear dose-response relationships were noted between SSB intake and cancer mortality and between ASB intake and both all-cause and cancer mortality. Non-linear associations were identified for ASB intake with CVD mortality and for SSB intake with both all-cause and CVD mortality. Evidence regarding 100% fruit juice and mortality remained inconclusive [64].

NAFLD has also been linked to soft drink consumption. In a prospective cohort of Chinese adults (42,048 person-years; median follow-up 4.2 years), 2,888 first-incident NAFLD cases were documented. After adjusting for demographics, lifestyle, dietary intake, and inflammatory markers, hazard ratios (HRs) for incident NAFLD increased with frequency of soft drink consumption: <1 serving/week (reference), 1 serving/week (HR: 1.18; 95% CI: 1.03–1.34), 2–3 servings/week (HR: 1.23; 95% CI: 1.08–1.40), and ≥ 4 servings/week (HR: 1.47; 95% CI: 1.25–1.73; P < 0.0001). Sensitivity analyses using HSI-defined NAFLD yielded consistent results, indicating a dose-dependent relationship between soft drink consumption and NAFLD risk [65].

Public health policies and interventions

Public health policies and interventions are vital in curbing the rising consumption of CSDs and mitigating their associated health risks. One of the most effective strategies adopted by governments worldwide has been the implementation of regulations such as soda taxes and advertising restrictions. Soda taxes, which place an additional charge on sugary beverages, have gained global traction as a powerful tool to reduce excessive consumption [38]. Studies have demonstrated the impact of these taxes in reducing purchases and intake of sugary drinks. For instance, Mexico’s 2014 soda tax resulted in a 12% decline in soda sales in its first year, with sustained reductions in subsequent years. These outcomes are particularly encouraging in lower-income populations, where health disparities related to obesity and diabetes are most pronounced [89, 90]. However, challenges remain in implementing such policies, including resistance from the beverage industry, lobbying against taxation, and uncertainties regarding long-term impacts on body weight and consumption patterns, even when initial reductions in purchases are observed.

Additionally, advertising restrictions targeting sugary beverages, especially those aimed at children, can significantly decrease the appeal of CSDs among younger audiences. Countries like Chile have implemented strict advertising regulations, which have proven effective in lowering consumption rates among vulnerable groups such as children [91].

Public awareness campaigns and health promotion initiatives also play a crucial role in reducing excessive CSD consumption. These campaigns aim to educate the public on the negative health effects of high sugar intake and promote healthier beverage choices [92]. Collaborative health promotion efforts, often involving partnerships among public health organizations, non-profits, and community leaders, help create environments conducive to healthier decision-making. Campaigns promoting water consumption, educating consumers on reading nutrition labels, and highlighting the health risks of CSDs have demonstrated success in changing consumer behaviors [93]. For example, “Choose Water” initiatives encourage individuals to opt for water over sugary beverages, combining community events, educational materials, and social media outreach to maximize their impact. Such campaigns empower individuals to make informed dietary choices and contribute to a cultural shift toward healthier habits [94].

Schools and workplaces are particularly pivotal settings in shaping beverage choices and promoting sustainable behavior change. Schools provide critical environments for establishing healthy habits in children and adolescents, making them ideal for implementing beverage policies that limit access to sugary drinks [95]. Many school districts have adopted healthier beverage guidelines, prioritizing water, milk, and 100% fruit juices in vending machines and cafeterias over CSDs. Research has shown that when schools eliminate or significantly reduce access to sugary beverages, students’ consumption declines, leading to healthier dietary patterns [96]. Workplaces also significantly influence employee health behaviors. Employers can introduce wellness programs promoting healthy eating and hydration, while offering healthier alternatives to sugary drinks in vending machines and cafeterias. Initiatives such as providing free or subsidized water stations, hosting nutrition workshops, and creating environments that encourage physical activity can further reduce CSD consumption among employees [97, 98].

Alternatives to carbonated soft drinks

As public health concerns about the consumption of CSDs grow, there is an increasing emphasis on promoting healthier beverage options that can effectively replace these sugary drinks. Water remains the most straightforward and beneficial alternative, serving as a fundamental component of a healthy diet [99]. Hydration is vital for overall health, and drinking sufficient water can help manage weight, improve digestion, and support various bodily functions. Additionally, flavored water, infused with natural ingredients such as fruits, herbs, or vegetables, has gained popularity as a refreshing alternative that offers taste without the added sugars found in CSDs. Such options can provide a flavorful yet healthy choice for consumers looking to reduce their sugar intake while still enjoying variety in their beverages.

Herbal teas have also emerged as an excellent alternative to CSDs, offering numerous health benefits without added sugars or artificial ingredients. Rich in antioxidants, herbal teas can support various aspects of health, including digestion, relaxation, and immunity [100, 101]. Moreover, the wide range of flavors and potential health benefits associated with different herbal blends such as chamomile for relaxation, peppermint for digestion, or ginger for anti-inflammatory properties appeals to consumers seeking flavorful and health-promoting options. Unsweetened iced teas, both herbal and traditional, provide additional alternatives that can be enjoyed cold, making them a satisfying choice for those looking to avoid carbonated beverages [102, 103].

Juices made entirely (100%) from fruit, while providing essential vitamins, minerals, and phytonutrients, should be consumed in moderation due to their naturally high sugar content. Public health guidelines recommend limiting intake to small servings (typically 4–6 ounces) and prioritizing whole fruit consumption to maximize fiber intake and reduce sugar spikes [104]. This clarification ensures that fruit juice is presented as a partial alternative rather than an ideal replacement for CSDs.

In addition to these traditional alternatives, there is a growing market for low-sugar or sugar-free beverages that cater to health-conscious consumers [105]. Many beverage manufacturers have responded to the demand for healthier options by developing beverages that are low in sugar or sweetened with natural, non-caloric sweeteners such as stevia or erythritol. The acceptance of these alternatives has been increasing, particularly among consumers who are mindful of their sugar intake and overall health. Studies indicate that many individuals are willing to replace their regular CSDs with lower-sugar options, especially if they taste good and are readily available.

The public’s acceptance of low-sugar or sugar-free beverages is also reflected in the rising sales of products marketed as healthier choices [106]. The sparkling water industry, in particular, has seen rapid growth, with flavored sparkling waters offering carbonation without added sugars or high caloric content. This trend demonstrates how the market is innovating in response to increased health awareness, providing consumers with enjoyable, low-calorie alternatives to traditional sodas. Additionally, the introduction of plant-based beverages, such as coconut water or almond milk, has provided even more variety in the beverage market. These alternatives often contain fewer calories and sugars than CSDs while offering distinct flavors and nutritional benefits [107].

In conclusion, there is a wealth of healthier beverage options available that can effectively replace carbonated soft drinks. From water and herbal teas to moderated consumption of 100% fruit juices and low-sugar or sparkling water alternatives, consumers have a variety of choices that can support their health and wellness goals. The growing public acceptance of these alternatives highlights the importance of promoting awareness and accessibility, making it easier for individuals to choose healthier beverages and ultimately reduce their dependence on sugary drinks. As the beverage landscape continues to evolve, public health initiatives can play a critical role in encouraging the shift towards these healthier options, paving the way for improved health outcomes and reduced risks associated with CSD consumption.

Conclusion

In conclusion, the consumption of CSDs poses significant public health challenges, contributing to a wide array of adverse health outcomes, including obesity, type 2 diabetes, dental decay, cardiovascular diseases, and compromised bone health. Robust evidence consistently demonstrates the magnitude of the health risks associated with SSB and CSD consumption. For instance, each additional daily serving of sugar-sweetened beverages is associated with a 27% increase in the risk of type 2 diabetes, and daily consumers of carbonated soft drinks exhibit a hazard ratio of 4.69 for fracture, compared to non-consumers. These findings underscore that reducing CSD intake is not only a matter of preference but an urgent public health priority. The evidence reviewed underscores the profound metabolic and physiological consequences of excessive sugar intake and the elevated risks of chronic disease associated with regular CSD consumption. Furthermore, the demographic patterns of CSD consumption, shaped by socioeconomic factors and aggressive marketing strategies, highlight the critical need for targeted and equitable public health interventions. Notably, Mexico’s excise tax on sugar-sweetened beverages resulted in a 12% decline in soda sales during the first year, with the largest reductions observed among low-income households. This demonstrates how well-designed fiscal interventions can both improve population health and help reduce socioeconomic health disparities. Additionally, schools and workplaces are critical settings for shaping beverage preferences, emphasizing their central role in promoting healthier, equitable consumption environments. Despite these challenges, there is a growing shift towards healthier beverage alternatives, such as water, herbal teas, and low-sugar options, which offer promising opportunities for enhancing public health outcomes.

However, it is important to acknowledge certain limitations of this review. Although the search strategy was structured and utilized multiple databases with diverse search terms, the process did not fully replicate the methodological rigor of a systematic review. As a result, the possibility of selection bias cannot be entirely ruled out, and the final set of included studies may not encompass all available evidence on the health impacts of carbonated soft drink consumption. Moreover, variability in study designs, populations, and measurement methods across the included research may limit the direct comparability of findings. Future systematic reviews and meta-analyses will be essential to validate and extend the conclusions presented here.

Looking forward, future research should prioritize the long-term health effects of CSD alternatives and investigate the socio-cultural drivers of beverage choices. This can be organized into three thematic directions: (1) Evaluation of Alternative Beverage Health Effects, focusing on the long-term metabolic and cardiovascular outcomes of ASBs; (2) Targeted Policy Effectiveness, examining interventions in high-risk groups such as children, adolescents, and low-income populations to identify strategies that effectively reduce consumption disparities; and (3) Socio-Environmental and Cultural Determinants, exploring how schools, workplaces, and community environments can be leveraged to shift norms toward healthier beverage choices. Understanding how public health policies like soda taxes, advertising restrictions, and educational initiatives impact consumption behaviors can offer valuable insights for refining these strategies, particularly for protecting vulnerable populations such as children and adolescents. Additionally, more research is needed to explore the role of schools and workplaces in shaping healthier dietary habits, as these environments are pivotal in promoting long-lasting behavior change.

Public health policies must be adaptive and responsive to changing consumption trends, particularly as the beverage industry promotes new alternatives such as artificially sweetened beverages. Continuous monitoring and policy adjustment are essential to ensure that emerging products do not undermine health gains. Collaborative efforts among government agencies, health organizations, and the beverage industry are essential for developing comprehensive strategies that prioritize both health promotion and disease prevention. This includes raising public awareness about the risks of CSD consumption, highlighting the benefits of healthier alternatives, and ensuring access to nutritious beverage options in schools, workplaces, and communities. Ultimately, addressing the public health implications of carbonated soft drink consumption requires a multifaceted and coordinated approach involving ongoing research, effective policy-making, and robust community engagement. By creating an environment that encourages healthier beverage choices, we can significantly reduce the burden of diet-related diseases and promote a healthier future for individuals and communities worldwide.

Authors’ contributions

Markos Makiso, Urugo : conceptualization, data organization, writing—original draft, and editing. Banchiywsen Kidane: Conceptualization, organization, review, proofreading, editing, final approval, Samrawit Firew : review, proofreading, editing, final approval, and supervision, Wesena Hundea : review, proofreading, editing, final approval, and supervision, Senay Demeke: organization, review, proofreading, editing, final approval, Aelaf Semu : organization, review, proofreading, editing, final approval, Selam Getachew : review, proofreading, editing, final approval, Yohannis Yirga : organization, review, proofreading, editing, final approval.

Funding

No funding.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.