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. 2018 Feb 20;5:6. doi: 10.1186/s40608-017-0178-9

The negative impact of sugar-sweetened beverages on children’s health: an update of the literature

Sara N Bleich 1,, Kelsey A Vercammen 2
PMCID: PMC5819237  PMID: 29484192

Abstract

While sugar sweetened beverage (SSB) consumption has declined in the last 15 years, consumption of SSBs is still high among children and adolescents. This research synthesis updates a prior review on this topic and examines the evidence regarding the various health impacts of SSBs on children’s health (overweight/obesity, insulin resistance, dental caries, and caffeine-related effects). We searched PubMed, CAB Abstracts and PAIS International to identify cross-sectional, longitudinal and intervention studies examining the health impacts of SSBs in children published after January 1, 2007. We also searched reference lists of relevant articles. Overall, most studies found consistent evidence for the negative impact of SSBs on children’s health, with the strongest support for overweight/obesity risk and dental caries, and emerging evidence for insulin resistance and caffeine-related effects. The majority of evidence was cross-sectional highlighting the need for more longitudinal and intervention studies to address this research question. There is substantial evidence that SSBs increase the risk of overweight/obesity and dental caries and developing evidence for the negative impact of SSBs on insulin resistance and caffeine-related effects. The vast majority of literature supports the idea that a reduction in SSB consumption would improve children’s health.

Electronic supplementary material

The online version of this article (10.1186/s40608-017-0178-9) contains supplementary material, which is available to authorized users.

Keywords: Sugar-sweetened beverages, Children’s health

Background

Sugar sweetened beverages (SSB) – which include drinks with added sugar such as soda, fruit drinks and energy drinks – are frequently consumed by children and adolescents in the United States (U.S.) [1]. There is evidence that consumption of SSBs has recently begun to decline in the U.S., with this decrease largely driven by fewer children consuming these beverages [2, 3]. From 2003 to 2014, the percentage of children in the U.S. consuming at least one sugar-sweetened beverage on a typical day declined significantly from 80% to 61% [3]. Much of this decline was driven by a decrease in the percentage of young children ages 2 to 5 consuming SSBs, although the decline was significant for all age groups. Over the same period, consumption from caloric beverages (SSBs, milk and 100% juice) declined from 463 to 296 daily calories, and the fraction of all beverage calories from SSBs decreased from 49% to 45% [3]. Within SSBs, the number of calories from soda and fruit drinks consumed per day declined from 116 kcal to 49 kcal and 70 kcal to 31 kcal, respectively [3]. Despite these important declines, consumption of SSBs by children and adolescents in the U.S. still remains high. In 2013–2014, 46.5% of children aged 2–5, 63.5% of children aged 6–11 and 65.4% of adolescents aged 12–19 reported consuming at least one SSB on a given day [3]. Additionally, high levels of SSB consumption persist among low-income and racial and ethnic minorities.

In light of the frequent consumption of SSBs among children and adolescents in the U.S., there has been an interest in critically examining associated health consequences. As a result, there has been a substantial rise in the number of studies investigating the health effects of SSBs over the past decade. Evidence has emerged linking SSB consumption to a number of health consequences among adults including weight gain [4, 5], cardiovascular risk factors (e.g., dyslipidemia) [6], insulin resistance and type 2 diabetes [7, 8] and non-alcoholic fatty liver disease [9]. Studies among children are more limited and have generally focused on weight gain [4] and dental caries [10], as well as insulin resistance to a lesser extent [11, 12]. An emerging body of research has also examined the association between caffeinated SSBs (e.g., energy drinks or colas) and caffeine-related health consequences including reduced sleep quality and headaches [13]. Given the growing number of studies assessing SSB-related health consequences, concise summaries of the evidence base are needed in order to inform policy and advocacy efforts focused on reducing SSB consumption.

This review aims to synthesize the existing evidence regarding the impact of SSB consumption on children’s health. Unlike previous reviews which have been limited in scope (e.g., focusing on a single outcome such as weight gain) [14, 15], this review summarizes evidence from cross-sectional, longitudinal and intervention studies on a broad range of health outcomes relevant to children including: obesity, insulin resistance, dental caries, and caffeine-related effects. A previous review published in 2009 summarized many early studies on SSBs and children’s health [16]. Using a narrative review approach, we update the literature by reviewing more recent studies published up until 2017.

Search selection

For each of the health impacts (obesity, insulin resistance, dental caries and caffeine-related effects), separate searches were conducted of PubMed, Web of Science and PAIS International. For all searches, a search hedge was created in three parts: 1) terms relevant to SSBs including “beverage” and “sodas”, 2) terms restricting to children and adolescents including “pediatric” and “teens” and 3) terms specific to the outcome being examined such as “body mass index” and “body weight” for the search on overweight and obesity risk (see Additional file 1: Appendix for full list of search terms). These search terms were chosen to retrieve the most relevant results using an iterative process in consultation with a medical librarian. For searches of PubMed, MeSH subject headings were used. In addition to database searches, reference lists of SSB reviews and articles were searched. Following the removal of duplicate studies, one author (K.V.) screened titles, abstracts and full-texts and another author (S.B.) confirmed the inclusion of these studies. Included studies had to be peer-reviewed articles examining the effects of SSBs on a specific health outcome, be limited to children and adolescents, and be published after January 1, 2007. We selected 2007 as the start date because the most recent relevant review [16] included studies published prior to this. Studies were excluded if they were not published in English, were not conducted in high-income countries (defined as membership in Organisation for Economic Co-operation and Development) or were grey literature. We limited our scope to high-income countries to promote generalizability of results.

Effects of SSBs on health outcomes in children

Overweight and obesity risk

A large number of studies have reported on the association between SSB consumption and overweight/obesity risk, with the majority of a cross-sectional [1735] or longitudinal design [3654] and only a few intervention studies (Table 1).

Table 1.

Studies on the the overweight/obesity risk associated with SSB consumption

Author, Year Setting Sample Size Sample Age Method of Diet Assessment SSB Unit of Analysis Primary Outcome Direction of Association Findings
Cross-Sectional Studies
Beck, 2013 Mexican American children recruited from enrollees of Kaiser Permanente Health Plan of Northern California 319 8-10 years Youth/ Adolescent FFQ Increment of a serving/day of soda (1 serving = 240ml) Odds of obesity Positive OR = 1.29 [95%CI: 1.13, 1.47]*
Bremer, 2010A Nationally representative sample of U.S. adolescents, NHANES, 1988-1994, 1999-2004 1988-1994:
3234
1999-2004:
6967
12-19 years Single 24-hour dietary recall interview Increment of a serving/day of SSB (1 serving =250g) Change in BMI percentile for age-sex Mixed
Null for one follow-up
Positive for one follow-up
1988-1994
β = 0.38 [SE: 0.45]
1999-2004
β = 0.93 [SE: 0.18]*
Bremer, 2010B Nationally representative sample of U.S. adolescents, NHANES, 1999-2004 6967 12-19 years Single 24-hour dietary recall interview Increment of a serving/day of SSB (1 serving =250g) Change in BMI percentile for age-sex Mixed
Positive in two sub-groups
Null in one sub-group
Non-Hispanic White:
β = 1.08 [SE: 0.21]*
Mexican-American:
β = 0.59 [SE: 0.29]*
Non-Hispanic Black:
β = 0.37 [SE: 0.26]
Clifton, 2011 Australian children as part of Australian National Children’s Nutrition and Physical Activity Survey 4400 2-16 years Single 24-hour dietary recall interview Consumed any amount of SSB in last 24 hours Proportion of overweight or obese children who consumed SSBs vs. proportion of non-overweight children
Proportion of obese children who consumed SSBs compared to proportion of non-overweight children
Mixed
Null for one comparison
Positive for one comparison
Overweight and Obese vs. Normal Weight
50% vs. 47%
No measure of variation reported
Obese vs. Normal Weight
59% vs. 47%*
No measure of variation reported
Coppinger, 2011 British schoolchildren in south-west London, UK 248 9-13 years Three day diary (Friday-Sunday) mL/day of SSB Correlation with BMI or BMI z-score Null No significant correlation [r= 0.05 for soft drinks and BMI, r=0.10 for fruit beverages]
Danyliw, 2012 Representative survey of Canadian children and adolescents 10,038 2-18 years Single 24-hour dietary recall interview Soft drink beverage cluster vs. moderate beverage pattern (mean beverage consumption in each cluster differed by gender and age group) Odds of overweight-obesity Mixed
Positive in one sub-group
Null in other sub-groups
Males, 6-11 years old
OR= 2.3 [95%CI: 1.2, 4.1] *
Females, 6-11 years old
OR = 0.8 [95%CI: 0.4, 1.7]
Males, 12-18 years old
OR = 0.7 [95%CI: 0.4-1.2]
Females 12-18 years old
OR: 1.1 [0.6, 1.9]
Davis, 2012 Low-income Hispanic toddlers from Los Angeles WIC program, 2008 data 1483 2-4 years Interview about early-life feeding practices and nutritional intake No SSB vs. High SSB (≥2 SSBs/day) (1 serving = 12 ounces) Odds of obesity Positive OR= 0.69 [95%CI: 0.47, 1.00]*
Davis, 2014 Low-income Hispanic toddlers from Los Angeles WIC program, 2011 data 2295 2-4 years Interview about early-life feeding practices and nutritional intake No SSB vs. High SSB (≥2 SSBs/day), (1 serving = 12 ounces) Odds of obesity Positive AOR = 0.72 [95%CI: 0.5, 1.0]*
Denova-Gutiérrez, 2009 Adolescent children of workers at two institutes and one university in Mexico 1055 10-19 years Semi-quantitative FFQ Increment of a serving/day of sweetened beverage (1 serving = 240mL) Change in BMI
Odds of obesity
Positive β =0.33 95%CI: 0.2, 0.5]*
OR=1.55 [95%CI: 1.32, 1.80]*
Gibson, 2007 Children in the UK part of the UK National Dietary and Nutritional Survey of Young People 1294 7-18 years Seven day weighed food records Top tertile of caloric soft drink intake (>396kJ/day)) vs. bottom tertile (<163kj/day) Odds of overweight Weakly Positive OR=1.39 [95%CI: 0.96, 2.0]
Grimes, 2013 Nationally representative sample of Australian children 4283 2-16 years Two 24-hour dietary recalls More than one serving/day vs. less than one serving/day (1 serving = 250g) Odds of overweight-obese Positive OR=1.26 [95%CI: 1.03, 1.53]*
Gómez-Martinez, 2009 Representative sample of urban Spanish adolescents 1523 13-18 years Single 24-hour dietary recall Non-consumers vs. moderate consumption (<336g/day) vs. high consumption (>336g/day) of sweetened soft drinks Mean BMI Null No significant differences in BMI across SSB consumption groups
Ha, 2016 Combination of 5 studies conducted on Korean children between 2002 and 2011 2599 9-14 years Three day dietary records More than one serving/day vs. no SSB (1 serving = 200mL) Odds of obesity Mixed
Negative in one sub-group
Null in one sub-group
Males
OR: 0.52 [95%CI: 0.26, 1.05]*
Females
OR: 1.36 [95%CI: 0.62, 2.97]
Jiménez-Aguilar, 2009 Representative sample of Mexican adolescents who participated in Mexican National Health and Nutrition Survey 10,689 10-19 years Semi-quantitative FFQ Increment of a serving/day of soda (1 serving = 240ml) Change in BMI Mixed
Positive in one sub-group
Null in one sub-group
Males
β =0.17 [95%CI: 0.02, 0.32]*
Females
β =-0.07 [95%CI: -0.23, 0.10]
Note: these results are for soda. See full paper for fruit drinks, sugar beverages and SSBs.
Kosova, 2013 Nationally representative sample of U.S. children from NHANES, 1994-2004 4880 3-11 years Single 24-hour dietary recall interview Increment of a serving/day of SSB (1serving = 250g) Change in BMI percentile Mixed
Null overall and in some sub-groups
Positive in one sub-group
Overall
β =0.71
[SE=0.38]
3-5 year olds
β =-0.46 [SE=0.68]
6-8 year olds
β =0.19
[SE=0.65]
9-11 year olds
β =1.42
[SE=0.46]*
Linardakis, 2008 Children in public kindergartens in a single county in Greece 856 4-7 years Three day weighed dietary records High consumers (>250g/day) vs. non/low consumers of sugar-added beverage Odds of obesity Positive OR= 2.35*
No measure of variation reported
Papandreou, 2013 Greek children in Thessaloniki 607 7-15 years Three 24-hour dietary recalls High consumers (>360mL/day) vs. low (<180mL/day) of SSBs Odds of obesity Positive OR = 2.57 [95%CI: 1.06, 3.38]*
Schröder, 2014 Representative sample of Spanish adolescents 1149 10-18 years Single 24-hour dietary recall Soft drink beverage cluster (mean= 553g) vs. whole milk cluster One-unit increase in BMI z-score Positive Males
OR = 1.29 [95%CI: 1.01, 1.65]*
Note: No soft drink cluster was identified for females
Valente, 2010 Elementary school children in Portugal 1675 5-10 years Semi-quantitative FFQ >2 servings/day (330mL) vs. less than 1 serving/day Odds of overweight Null Males
OR: 0.64
[95%CI: 0.33, 1.52]
Females
OR: 0.63 [95%CI: 0.33, 1.22]
Longitudinal Studies
Ambrosini, 2013 Adolescent offspring from Australian Pregnancy Cohort (Raine) Study 1433 14 years old, followed-up at 17 years old FFQ, at baseline and follow-up Movement into top tertile of SSB consumption (>1.3 servings/day) at follow-up vs. remaining in lower SSB tertile Odds of overweight-obesity at follow-up Mixed
Null in one sub-group
Positive in one sub-group
Males:
OR: 1.2 [95%CI: 0.6, 2.7]
Females
OR: 4.8 [95%CI: 2.1, 11.4] *
Chaidez, 2013 Convenience sample of Latino mother and toddler pairs 67 mothers 1-2 years, followed-up for 6 months Four 24-hour dietary recall (2 at baseline, 2 at follow-up) High SSB consumption (higher than median) vs. low SSB consumption (lower than median) BMI z-score, weight for height z-score, and weight for age z-score at follow-up Mixed
Positive for one measure.
Null for other measures.
Weight for height z-score
β =0.46*
BMI z-score
β =0.47
Weight for age z-score
β =0.13
No measure of variation reported
DeBoer, 2013 Nationally representative sample of toddlers in the U.S. 9600 9 months, 2, 4 and 5 years (followed-up at each age) Computer-assisted interview with questions about beverage consumption, at each follow-u ≥1 serving/day vs. <1 serving/day of SSB (1 serving = 8 ounces) BMI z-score at follow-up (between 2 and 4 years and between 4 and 5 years) Mixed Measure of association not reported.
Positive for change between 2 and 4 years, null for change between 4 and 5 years.
Dubois, 2007 Representative sample of children in Quebec, Canada 1944 2.5, 3.5, 4.5 years (followed-up at each age) Single 24-hour dietary recall and FFQ at each follow-up Regular consumers (4-6 servings/week between meals) between ages 2.5 and 4.5 years vs. non-consumers of SSBs Odds of being overweight at follow-up Positive OR: 2.36 [OR: 1.10, 5.05]*
Field, 2014 Children of participants in the Nurses’ Health Study 2 in the U.S. 7559 9-16 years, followed-up for 7 years Youth/ Adolescent FFQ, at baseline and follow-up Increment of baseline and change in sports drink serving/day (serving =1 can) BMI score at follow-up Mixed Results differed depending on type of SSB and whether predictor was baseline intake or change in intake. Results below are for sports drink intake.
Females
Baseline:
β =0.29 [95%CI: 0.03, 0.54]*
Change:
β =0.05 [95%CI: =-0.19, 0.29]
Males:
Baseline:
β =0.33 [95%CI: 0.09, 0.58]*
Change:
β =0.43 [95%CI: 0.19, 0.66]*
Fiorito, 2009 Non-Hispanic white girls in the U.S. 170 5 years, assessed biennially until 15 years Three 24-hour dietary recalls at each follow-up ≥2 servings of SSB/day vs. < 1 serving of SSB/day at age 5, (1 serving = 8 ounces) Percentage overweight in each SSB consumption group at each follow-up Positive 5 years old
≥2: 38.5%
<1: 16.1%
7 years old
≥2: 46.2%
<1: 15.1 %
9 years old
≥2: 46.2%
<1: 24.2%
11 years old
≥2: 53.9%
<1: 21.7%
13 years old
≥2: 46.2%
<1: 22.2
15 years old
≥2: 32.0
<1: 18.5
*Significant main effect
Jensen, 2013A Danish children entering school in Copenhagen participating in intervention study 366 6, 9, 13 years (followed-up at each age) 7 day dietary record at 6 and 9 years Increment of a serving/day of SSBs at 6 or 9 years, (1 serving = 100g) Change in BMI from 6 to 9 years, 6 to 13 years or 9 to 13 years Null Intake at age 6, change from 6 to 9 years
β =-0.005 [95%CI:
-0.059, 0.0489]
Intake at age 6, change from 6 to 13 years
β =-0.059 [95%CI:
-0.145, 0.027]
Intake at age 9, change from 9 to 13 years
β =0.008 [95%CI:
-0.098, 0.113]
Note: these results are for SSBs. See full paper for sweet drinks and soft drinks separately.
Jensen, 2013B Comparison groups of two quasi-experimental intervention studies in Australia (BAEW, IYM) 1465 4-18 years, followed-up approximately 2 years later Asked participants how much SSB consumed yesterday or last school day Increment of a serving/day of sweet drink at baseline, (1 serving = 100mL) BMI z-score at follow-up Null BAEW study:
Β=0.005 [95%CI:
-0.003, 0.012]
IYM study:
β =0.004 [95%CI:
-0.002, 0.01]
Kral, 2008 Cohort of white children in U.S. born at different risks for obesity (based on maternal pre-pregnancy BMI) 49 3-6 years, followed-up at ages 3, 4, 5 and 6 years Three day weighed food record Change in calories from SSB from ages 3-5 Change in BMI z-score over follow-up Null Measure of association not reported
Laska, 2012 Adolescents enrolled in two longitudinal cohort studies in the U.S. (IDEA, ECHO) 693 6th to 11th grade, followed-up 2 years later Three telephone-administered 24-hour dietary recalls Increment of a serving/day (1 serving = not reported) BMI at follow-up Mixed
Positive in one sub-group
Null in one sub-group
Males
β =0.25 [SE: 0.10]*
Females
β =-0.09 [SE: 0.16]
Note: Above association was no longer significant when correcting for multiple testing
Laurson, 2008 Cohort of children in three rural U.S. states 268 10 years, followed-up for 18 months Questionnaire asking about SSB consumption SSB consumption (1 serving = not reported) Spearman correlation with BMI at baseline or follow-up or change in BMI Null Males
Baseline
r= 0.009
Follow-up
r= 0.033
Change
r=0.041
Females
Baseline
0.073
Follow-up
0.077
Change
-0.033
Lee, 2015 Non-Hispanic Caucasian and African-American girls in the U.S. 2021 9-10 years, followed-up for 1 year Three day food records Increment of one teaspoon of added sugar (liquid form) Change in BMI z-score at follow-up Positive β = 0.002 [95%CI: 0.001, 0.003)*
Leermakers, 2015 Dutch children in population-based prospective cohort study 2371 13 months, followed-up at ages 2, 3, 4 and 6 Semi-quantitative FFQ, validation against 24-hour recalls High intake (15 servings/week) vs. low intake (3 servings/week) of sugar-containing beverages at 13 months, (1 serving = 150ml) Change in BMI z-score at different follow-up ages Mixed
Null in some sub-groups
Positive in other sub-groups
Males
2 year olds
β =-0.01 [95%CI: -0.15, 0.12]
3 year olds
β = -0.01 [95%CI: -0.15, 0.12]
4 year olds
β =0.01 [95%CI:
-0.12, 0.09]
6 year olds
β =0.05 [95%CI:
-0.08, 0.18]
Females
2 year olds
β =0.15 [95%CI: 0.01, 0.30]*
3 year olds
β =0.14 [95%CI: 0.01, 0.27]*
4 year olds
β =0.13 [95%CI: 0.01, 0.25]*
6 year olds
β =0.11 [0.00, 0.23]*
Libuda, 2008 German adolescents participating in longitudinal study (DONALD) 244 9-18 years, followed-up for 5-years Three day weighed dietary records Baseline and change in regular soft drink consumption BMI z-score at follow-up Null Males
Baseline soft drink consumption
β =0.046
Change in baseline soft drink consumption
β =0.009
Females
Baseline soft drink consumption
β =-0.291
Change in baseline soft drink consumption
β =0.055
Measures of variation not reported
Lim, 2009 Low-income African-American children 365 3-5 years, followed-up for 2 years Block Kids FFQ Increment of an ounce/day of SSB at baseline Odds of incidence of overweight at 2-year follow-up Positive OR=1.04 [95%CI: 1.01, 1.07]*
Millar, 2014 Nationally representative cohort of Australian children 4164 4-10 years, followed-up for 6 years Parental interview asked about SSB consumption in past 24 hours Increment of a serving/day (serving = not reported) Change in BMI z-score at follow-up Positive β =0.015 [95%CI: 0.004, 0.025]*
Pan, 2014 Children in Infant Feeding Practices Cohort Study in U.S. 1189 10-12 months, followed-up at 6 years Survey including questions about SSB consumption Ever consumed SSBs vs. never consumed during infancy
High intake of SSBs (≥3 times/week) vs. no intake of SSBs during infancy
Odds of obesity at 6 years Positive Ever Consumed vs. Never consumed:
OR: 1.71
[95%CI: 1.09, 2.68]*
High vs. No SSBs
OR: 2.00 [95%CI: 1.02, 3.90]*
Vanselow, 2009 U.S. Adolescents from various socioeconomic and ethnic background in Minneapolis/St Paul metropolitan area 2294 Adolescents, followed-up for 5 years Youth/ Adolescent FFQ Stratified by different number of soft drinks serving/week (0, 0.5-6, ≥6) Change in BMI over 5-year follow-up Null 0 servings
β =1.74 [SEM= 0.18]
0.5-6 servings
β =1.92 [SEM=0.10]
≥7 servings
1.80 [SEM=0.15]
No significant differences across groups
Note: these results are for soft drinks. See full paper for punch, low-calorie soft drinks, etc.
Weijs, 2011 Dutch children 120 4-13 months, followed-up 8 years later Two day dietary record Beverage sugar intake per one percent of energy intake Odds of overweight Positive OR: 1.13 [95%CI: 1.03, 1.24]*
Zheng, 2014 Danish children part of European Youth Heart Study 283 9 years, followed-at ages 15 and 21 24-hour dietary recall, supplemented by qualitative food record from same day, conducted at baseline and first follow-up ≥1 serving (12 ounces) vs. none at 9 years or 15 years
Increase in SSB serving from 9 to 15 years vs. no change
Change in BMI from 9 to 21 years or from 15 to 21 years Mixed Change in BMI from 9 to 21 years, using 9 years SSB as predictor
1.42 [SE: 0.68]
Change in BMI from 15 to 21 years, using 15 years SSB as predictor
0.92 [SE: 0.54]*
Change in BMI from 15 to 21 years, using
change in SSB from 9 to 15 years as predictor
0.91 [SE: 0.57]
Intervention Studies
Author, Year Setting Sample Size Sample Age Intervention Control Primary Outcome Direction of Association Findings
de Ruyter, 2012 Normal weight Dutch children 641 4-11 years 250mL sugar-free, artificially sweetened beverage Similar sugar-containing beverage (104 calories) Difference in change of BMI z-score from baseline at 18-month follow-up Positive -0.13 [95%CI:
-0.21, -0.05]*
Ebbeling, 2012 Overweight and obese adolescents in U.S. who reported consuming at least 12oz of SSB/day 224 Grade 9 or 10 1-year intervention designed to decrease SSB consumption No beverage (given supermarket gift cards as retention strategy) Difference in change of BMI z-score from baseline to 1 year and from 1 year to 2 years (Change in experimental group minus change in control group) Mixed 1-year follow-up
-0.57 [SE: 0.28]*
2-year follow-up
-0.3 [SE: 0.40]
James, 2007 Longitudinal follow-up of children involved in intervention in United Kingdom 434 7-11 years Discouraged children from consuming SSBs and provided one hour of additional health education during each of four school terms No beverage Odds of overweight at 1 year and 3-years after baseline intervention (intervention ended at 1 year) Mixed 1-year follow-up
OR=0.58 [95%CI: 0.37, 0.89] *
3-year follow-up
OR=0.79 [95%CI: 0.52, 1.21]

Note: *indicates statistical significance (p<0.05) as reported by each study

Cross sectional studies

Most cross-sectional studies found significant positive associations between SSB intake and obesity risk among children and adolescents [1719, 2125, 27, 2932, 34, 35, 55]. For example, among 12 to 19 year olds in the 1999–2004 National Health and Nutritional Examination Survey (NHANES), each additional SSB serving (250 g) consumed per day was associated with a 0.93-percentile increase in Body Mass Index (BMI) z-score [34]. These positive findings were well-replicated across a range of OECD countries, including Canada, Spain, Greece and in Australia where those who consumed more than one SSB servings (≥250 g) per day were 26% more likely to be overweight or obese compared to those who consumed less than one serving per day [27]. They are also consistent with results focused on specific sub-groups such as among Mexican-American children aged 8–10 years where each additional SSB serving (240 mL) per week was associated with a 1.29 greater odds of obesity [17] and among toddlers living in low-income families where no SSB intake was associated with a 31% lower obesity prevalence compared to households where toddlers consumed two or more SSB servings (serving = 12 fluid ounces) per day [23].

Some of the cross-sectional studies found positive associations only within subsets of the sample [18, 19, 21, 29, 32, 35, 55], including: boys [32, 35], boys aged 6 to 11 [21], children aged 9 to 11 [29], and among Mexican-American and non-Hispanic White adolescents only [18].

A small number of cross-sectional studies reported null findings [20, 26, 33], and one study conducted in Korea among 9 to 14 year olds reported an inverse association among males [28].

Longitudinal studies

Like the cross-sectional data, longitudinal studies generally demonstrated that increased SSB consumption was associated with weight-related outcomes among children and adolescents [38, 39, 4749, 51, 53, 56]. For example, among a nationally representative survey of 2 to 5 year olds in the U.S., children who consumed more than one SSB serving (serving = 8 fluid ounces) per day at 2 years old had a significantly greater increase in BMI z-score over the next 2 years compared to infrequent/non SSB drinkers [38]. Two of the positive studies examined longitudinal associations between SSB consumption and obesity risk among minority populations, with one finding that high SSB intake (defined as greater than median intake in study population) among Latino toddlers was associated with a 0.46 unit increase in weight for height z-score at 6-month follow-up [37] and the other finding that SSBs were positively associated with 2-year overweight risk among African-American preschool children [47].

Some studies found mixed results [3638, 40, 44, 45, 52], with two reporting the positive association between SSB intake and increased weight was only significant among girls [36, 45]. The first study found high SSB intake (≥15 servings/week) at 13 months old was significantly associated with an increased BMI among girls at ages 2, 3, 4, and 6 years old [45]. Another study found that girls who moved to the top tertile of SSB consumption (>335 g/day) between 14 and 17 years of age had increased BMI and nearly a five-fold greater odds of overweight or obesity risk compared to girls who remained in the lowest tertile of SSB consumption [36]. One study found a positive association when using SSB consumption at 15 years to predict change in BMI from ages 15–21 and found null results when using SSB consumption at 9 years as a predictor [52].

Some of the longitudinal studies found no association between SSBs and BMI or BMI z-scores [4144, 46, 50, 54, 57].

Intervention studies

A small number of intervention studies have examined SSB consumption and overweight and obesity risk among children [5860]. Three recent randomized controlled trials found a reduction in BMI or obesity risk in the intervention group compared to the control. De Ruyter and colleagues conducted a double-blinded placebo-controlled trial wherein 641 normal weight Dutch children were randomized to receive either a 250 mL of an SSB or a sugar-free beverage each day for 18 months [58]. At the end of the trial, the difference in BMI z-score was significantly different between the two groups, with the SSB group increasing on average by 0.15 units (compared to 0.02 units in the sugar-free group). The second study randomized 224 overweight and obese American adolescents who regularly consumed SSBs to either participate in a program to reduce SSB consumption or receive no intervention [59]. At the end of the 1-year intervention, those in the intervention group had beneficial changes in BMI and weight compared to those who did not receive the intervention, but these differences were no longer significant when participants were followed-up for an additional year after the end of the intervention. However, in a pre-planned subgroup analysis of Hispanic participants, there were significant differences in BMI between groups at both follow-up periods. The third study was a cluster randomized trial in which schools in the United Kingdom were randomized to either an intervention discouraging consumption of SSBs or no intervention for one year [61]. A significant difference in BMI z-score and overweight/obesity risk between groups was observed at the end of the first year, supporting a positive association between SSBs and obesity risk [61]. Two years after the intervention had been discontinued, the researchers completed a follow-up assessment and reported the differences between the groups were no longer significant [60].

Insulin resistance

A modest number of studies reported a positive association between SSB consumption and insulin resistance risk among children and adolescents, with the majority conducted cross-sectionally [6265], one conducted longitudinally [66] and no intervention studies conducted (Table 2).

Table 2.

Studies on the insulin resistance risk associated with SSB consumption

Author, Year Setting Sample Size Sample Age Method of Diet Assessment SSB Unit of Analysis Primary Outcome Direction of Association Findings
Cross-Sectional Studies
Bremer, 2009 Nationally representative sample of U.S. adolescents, NHANES, 1994-2004 6967 12-19 years Single 24-hour dietary recall interview Increment of a serving/day (serving = 250g) Change in HOMA-IR Positive β = 0.05 [SE= 0.02]*
Bremer, 2010 Nationally representative sample of U.S. adolescents, NHANES, 1999-2004 6967 12-19 years Single 24-hour dietary recall interview Increment of a serving/day (serving = 250g) Change in HOMA-IR Mixed Non-Hispanic White:
β= 0.06 [SE=0.02]*
Non-Hispanic Black:
β=0.12 [SE=0.05]*
Mexican Americans:
β=0.04 [SE=0.04]
Kondaki, 2012 Adolescents in large multicenter European study 546 12-17 years Mini FFQ from Health Behavior in School-Aged Children study ≥1 time/day vs. <1 time/week
5-6 times/week vs. <1 time/week
2-4 times/week vs. <1 time/week, (serving = not reported)
Change in HOMA-IR Positive ≥1 time/day vs. ≤ 1 time/week
β = 0.19 [95%CI: 0.003, 0.38]*
5-6 times/week vs. ≤1 time/week
β = 0.28 [95%CI: 0.07, 0.49]*
2-4 times/week vs. ≤ 1 time/week
β =0.080 [95%CI:
-0.084, 0.245]
Santiago-Torres, 2016 Hispanic children attending inner-city school in Milwaukee 187 10-14 years Block for Kid’s FFQ with Hispanic foods SSB consumption, (serving = not reported) Change in HOMA-IR Positive β =0.104*
No measure of variation reported
Wang, 2012 Caucasian children recruited from primary schools in Canada 632 8-10 years Three 24-hour dietary recalls Increment of a serving/day (serving = 100ml) Change in HOMA-IR Mixed
Null overall
Positive in one sub-group
Null in one sub-group
Among all children:
β =0.024
> 85th BMI percentile
β = 0.097*
<85th BMI percentile
β =-0.027
No measure of variation reported
Longitudinal Studies
Wang, 2014 Caucasian Canadian children with at least one obese parent 564 8-10 years Three 24-hour dietary recalls Increment of 10g/day of added sugar from liquid sources HOMA-IR Positive Among all children:
0.091 [95%CI: 0.034, 0.149] *
Overweight/ obese:
0.121 [95%CI: 0.013, 0.247] *
Normal weight:
0.046 [95%CI:
-0.003, 0.096]

Note: *indicates statistical significance (p<0.05) as reported by each study

Cross sectional studies

A number of cross-sectional studies found a positive association in the whole or a subset of their study population [6265]. For example, among 12–19 year olds in NHANES, each additional SSB serving (250 g) consumed per day was associated with a 5% increase in HOMA-IR (a marker of insulin resistance which is calculated using fasting glucose and insulin levels) [55]. One study reported associations by race, with positive associations found among White and African Americans, but null associations among Mexican Americans [18]. Another study reported a stronger association between SSB consumption and higher HOMA-IR among overweight/obese participants compared to normal weight participants [64].

Longitudinal studies

Only one longitudinal study was conducted to examine this association, reporting that an additional 10 g/day of added sugar from liquid sources was associated with a 0.04 mmol/L higher fasting glucose, 2.3 pmol/L higher fasting insulin and a 0.01 unit increase in HOMA-IR over two year follow-up [66].

Dental caries

A growing number of studies have examined the relationship between SSB consumption and dental caries (cavities or tooth decay) among children and adolescents, with almost all evidence pointing towards a strong positive association (Table 3). While the majority of studies examining SSB intake and dental caries are cross-sectional [6782], there have been several longitudinal studies [8388] and one intervention study [89].

Table 3.

Studies on the dental caries risk associated with SSB consumption

Author, Year Setting Sample Size Sample Age Method of Diet Assessment SSB Unit of Analysis Primary Outcome Direction of Association Findings
Cross-Sectional Studies
Armfield, 2013 Australian children enrolled in school dental services 16,508 5-16 years Questionnaire given to parents asked about SSB consumption ≥3/day, 1-2/day vs. 0/day, (1 serving = “1 medium glass”) Decayed, missing and filled deciduous teeth (for ages 5-10)
Decayed, missing and filled permanent teeth (for ages 11-16)
Positive 5-10 years old
≥3 vs. 0 servings/day
β = 0.46 [95%CI: 0.29, 0.64]*
1-2 vs. 0 servings/day
β = 0.34 [95%CI: 0.23, 0.45]*
11-16 years old
≥3 vs. 0 servings/day
β = 0.27 [95%CI: 0.13, 0.41]*
1-2 vs. 0 servings/day
β = 0.16 [95%CI: 0.06, 0.26]*
Chi, 2015 Convenience sample of Alaska Native Yup’ik children 51 6-17 years Verbally administered survey, including questions on beverage consumption adapted from Beverage and Snack Questionnaire 40 grams/day of added sugar (i.e. amount of sugar in 12-ounce soda) measured using hair biomarker and self-report.
Note: Biomarker would include all sources of added sugar, not just liquid.
Proportion of carious tooth surfaces Mixed Biomarker:
6.4% [95%CI: 1.2, 11.6%]*
Self-Report:
Null. No measure of association reported.
Derlerck, 2008 Preschool children in four distinct geographical areas of Belgium 2533 3 and 5 year olds Questionnaire given to parents with structured open-ended questions about dietary habits Daily or more consumption of SSBs at night vs. none
Daily consumption of SSBs between meals vs. none
Odds of caries experience (using criteria from British Association for the Study of Community Dentistry) Positive SSB consumption at night
3 year-olds
OR= 7.96 [95%CI: 1.57, 40.51] *
5 year-olds
OR = 1.64 [95%CI: 0.18, 14.63]
SSB consumption between meals
3 year-olds
OR=1.47 [95%CI: 0.36, 6.04]
5-year olds
OR= 2.60 [95%CI: 1.16, 5.84] *
Evans, 2013 Low-income children recruited from pediatric dental clinics in D.C. and Ohio 883 2-6 years Parent-completed 24-hour recall and interviewer-administered FFQ Using 24-hour recall
1.7 to 14 servings SSB/day vs. 0 servings/day
Using FFQ
0.63 to 7 servings SSB/day vs. <0.16 servings/day (1 serving = 8 ounces)
Odds of severe early childhood caries Positive Using 24-hour recall
OR = 2.02 [95%CI: 1.33, 3.06]*
Using FFQ
OR = 4.63 [95%CI: 2.86, 7.49]*
Guido, 2011 Children from small rural villages in Mexico 162 2-13 years Questionnaire with questions about beverage consumption specific to ones sold in local stores Drinking soda at least onece/day Decayed, missing and filled deciduous teeth
Decayed, missing and filled permanent teeth
Positive No measures of association reported
p=0.71
p=0.04*
Hoffmeister, 2015 Random sample of children in southern Chile from a daycare center register 2987 2 and 4 years Survey filled out by parents with questions about sugary drink frequency >3 servings of sugary drinks/week at bedtime vs. ≤ 3 servings of sugar drinks/week at bedtime (1 serving = not reported) Prevalence ratio of decayed, missing and filled deciduous teeth Positive 2 year olds
PR = 1.43 [95%CI: 0.97, 2.10] *
4 year olds
PR = 1.30 [95%CI: 1.06, 1.59] *
Jerkovic, 2009 Children recruited from primary schools in northern region of the Netherlands, including low and high SES schools 301 6 and 10 years Questionnaire filled out by parents including information on nutritional care ≥5 glasses of fruit juice/soft drinks vs. ≤4 glasses of fruit juice/soft drinks Prevalence of caries Positive Measures of association not reported.
p<0.001 *
Jurzak, 2015 Pediatric patients from university dental clinic in Poland 686 1-6 years Questionnaire including questions about SSB consumption Frequent consumption of fruit juices and carbonated drinks vs. Infrequent consumption (1 serving = not reported) Odds of decayed, missing and filled teeth Mixed, depending on age 1-2 years old
2.60 [95%CI: 0.77, 8.74]
3-4 years old
2.23 [95%CI: 1.25, 3.96] *
5 years old
OR=2.134 [95%CI: 0.84, 5.44]
6 years old
OR= 2.25 [95%CI: 1.03, 4.92]*
Kolker, 2007 African American children with household incomes below 250% of the 2000 federal poverty level 436 3-5 years Block Kids FFQ Consumption of soda (1 serving = not reported) Odds of higher score of decayed, missing and filled deciduous teeth Null OR = 1.00 [95%CI: 1.0, 1.1]
Note: this result is for soda. See full paper for powdered drinks, sports drinks, fruit drinks, etc.
Lee, 2010 Convenience sample of healthy primary school children in Australia 266 4-12 years Prat Questionnaire asked about consumption of sweet drinks Sweet drinks consumed in the evening/night vs. no sweet drinks consumed Caries experience in past 12 months Positive 18% vs. 29%
p=0.004*
Measure of association not reported.
Majorana, 2014 Italian toddlers born to mothers attending two obstetric wards 2395 24-30 months Self-administered questionnaire for mothers with questions about SSB consumption ≥2 servings day vs. ≤1 servings of SSBs, (1 serving = 250mL) Odds of higher International Caries Detection and Assessment System score Positive OR = 1.18 [95%CI: 0.99-1.40]*
Mello, 2008 Sample of schoolchildren in Portugal 700 13 years Semi-quantitative FFQ ≥2 servings/week vs. ≤2 servings/week of soft drinks derived from cola, other soft drinks and any soft drinks (1 serving = not reported) Odds of ≥4 decayed, missing and filled teeth Positive Soft drinks from cola
OR = 2.23 [95%CI: 1.50, 3.31]*
Other soft drinks
OR = 1.54 [95%CI: 1.05, 2.26]*
Any soft drinks
OR = 1.88 [95%CI: 1.07, 3.29]*
Nakayama, 2015 Japanese infants 1675 18-23 months Questionnaire for parents or guardian with questions about SSB consumption Drinking soda ≥4 times/week vs. <4 times/week, (1 serving = not reported) Odds of early childhood caries Positive OR = 3.70 [95%CI: 1.07, 12.81] *
Pacey, 2010 Inuit preschool-aged children in Nunavut, Canada 388 3-5 years Past-month qualitative FFQ, 24-hour dietary recall (with repeat 24-hour recalls on 20% of sub-sample) Mean SSB consumption compared between groups of Reported Caries Experience Reported Caries Experience (RCE) Positive Mean SSB consumption /day among those with RCE
0.8 [SE=0.1]
Mean SSB consumption /day among those without RCE
0.5 [SE=0.1]
*Significant difference between groups.
Skinner, 2015 Random sample of adolescents in Australia 1187 14 to 15 years Questionnaire including questions about SSB consumption 0 cup of soft drinks or cordial vs. 1-2 cups per day vs. 3+ cups per day Mean decayed, missing and filled permanent teeth Positive 0 cups per day
Male: 1.14
Female: 0.81
1-2 cups per day
Male: 1.12
Female: 1.47
3+ cups per day
Male: 1.69
Female: 1.39
*Significant difference
between groups.
Measure of variation not reported
Note: this result is for soft drinks or cordial. See full paper for sweetened fruit juice, diet soft drinks and sports drinks.
Wilder, 2016 School-based sample of third grade students in Georgia, U.S. 2944 8 and 9 years Supplemental survey including questions about SSB consumption Increment of a serving/day of SSB, (1 serving = not reported) Prevalence ratio of caries experience Positive PR: 1.22 [95%CI: 1.13, 1.32]*
Longitudinal Studies
Lim, 2008 Low-income African American children in Detroit 369 3-5 years, followed-up 2 years later Block Kids FFQ Change from low SSB consumption cluster to high SSB consumption cluster vs. low consumers at both time periods Incident decayed, missing and filled deciduous teeth and incident filled surfaces at follow-up Positive New d 2 mfs:
IRR=1.75 [95%CI: 1.16, 2.64]*
New filled surface:
IRR=2.67 [95%CI: 1.36, 5.23]*
Park, 2015 U.S. children in Infant Feeding Practices Study II and Follow-up Study 1274 10-12 months, followed-up at 6 years of age 10 postpartum surveys through infancy, which asked about intake of SSBs during past 7 days Any SSBs vs. no SSBs during infancy
SSB introduction at or after 6 months, SSB introduction before 6 months vs. Never consumed SSBs during infancy
SSB consumption < 1 time/week, 1-3 times/week, ≥3 times/week vs. No SSBs
Dental caries in child’s lifetime at follow-up Mixed Any vs. No intake during infancy
OR = 1.14 [95%CI: 0.82, 1.57]
SSB intro at or after 6 months vs. no SSB
OR = 1.07 [95%CI: 0.76, 1.52]
SSB intro before 6 months vs. no SSB
OR = 1.29 [95%CI: 0.77, 2.17]
Consumed <1 time/week vs. No SSBs during infancy
OR = 1.15 [95%CI: 0.61, 2.18]
Consumed 1-3 times/week vs. No SSBs during infancy
OR = 0.85 [95%CI: 0.48, 1.49]
Consumed ≥3 times/week vs. No SSBs during infancy
OR = 1.83 [95%CI: 1.14, 2.92]*
Warren, 2009 Children in rural community in Iowa enrolled in WIC program 212 6-24 months, followed-up 9 and 18 months later Questionnaire asking about SSB consumption at each follow-up SSB consumption vs. no SSB consumption at baseline Odds of caries at 18-month follow-up Positive OR = 3.0 [95%CI: 1.1, 8.6]*
Warren, 2016 American Indian infants from Northern Plains Tribal community 232 Infants followed-up at 4, 8, 12, 16, 22, 28 and 36 months Validated beverage frequency questionnaire for parents adapted from Iowa Fluoride study, a 24-h dietary recall tool and food habit questionnaire Added-sugar beverage intake as proportion of total Odds of caries experience at follow-up Positive OR = 1.02 [95%CI: 1.00, 1.04]*
Watanabe, 2014 Japanese infants recruited from Kobe City Public Health Center 31,202 1.5 years, followed-up 21 months later (at ~3 years old) Questionnaire for parents asking about SSB consumption and frequency Daily SSB consumption vs. no SSB consumption, at baseline Odds of dental caries at 3-years Positive OR = 1.56 [95%CI: 1.46, 1.65]*
Wigen, 2015 Children in the Norwegian Mother and Child Cohort Study 1095 1.5 years, followed-up at 5 years old Questionnaire for parents asking about SSB consumption SSBs offered at least once a week vs. less than once a week, at 1.5 years Odds of decayed, missing and filled deciduous teeth Positive OR = 1.8 [95%CI: 1.1, 2.9]*
Intervention Studies
Author, Year Setting Sample Size Sample Age Intervention Control Primary Outcome Direction of Association Findings
Maupomé, 2010 American Indian toddlers in U.S. Four geographically separate tribal groups (3 intervention groups, 1 control group); Group A = 63 enrolled, 53 completed. Group B = 62 enrolled, 56 completed; Group C = 80 enrolled, 69 completed. Group D = NR. 18-30 months, 3-pronged approach: 1) increase breastfeeding, 2) limit SSB consumption, 3) promote consumption of water for thirst
Each intervention group measured at pre and post; also compared to control group to account for secular trends
No intervention received. Post-pre difference in fraction of affected mouths by incident caries (d1t and d2t) Positive d1t
Group A:
-0.574 [SDE: 0.159]*
Group B:
-0.300 [SDE: 0.140]*
Group C:
-0.631 [0.157]*
d2t
Group A:
-0.449 [SDE: 0.180]*
Group B:
-0.430 [SDE: 0.153]*
Group C:
-0.342 [SDE: 0.181]

Note: * indicates statistical significance (p<0.05) as reported by each study

Cross sectional studies

The vast majority of cross-sectional studies found evidence for a positive association between SSB consumption and dental caries [67, 6982]. For example, one study reported that the prevalence of caries was 22% higher for each additional SSB serving consumed by children per day [81]. Several studies replicated this positive association among low-income children [70, 73, 75], with one study reporting that high SSB consumption (≥5 oz/day) was associated with a 4.6 greater odds of dental caries compared to those with lower SSB consumption [70]. Some studies examined how specific timing of SSB consumption affects dental caries, with one study [72] finding an association with dental caries and SSBs consumed at bedtime and another [69] finding an association with dental caries and SSBs consumed at nighttime among 3 year-olds and for SSBs consumed between meals among 5-year olds.

One cross-sectional study reported null results, finding no association between self-reported SSB consumption and dental caries among Alaska Natives – a result which may have been related to the small sample size (N = 51) [68].

Longitudinal studies

All longitudinal studies included in this review found a positive or mixed association between SSB consumption and dental caries in at least part of the study population [8388]. One study reported that a high consumption of SSBs (≥3 servings per week) among infants 10 to 12 months old was associated with a 1.83 greater odds of dental caries at age 6, compared with infants who did not consume SSBs during infancy [84]. Some studies reported these positive findings among specific subgroups including: low-income [86], African American [83] and American Indian children [85]. For example, Lim et al. conducted a cluster analysis and reported that African American children who changed from being low consumers of SSBs at baseline (mean consumption = 567.4 mL/day) to high consumers of SSBs at 2-year follow-up (mean consumption = 1032.4 mL/day) had a 1.75 times higher mean number of new dental caries compared with high consumers of milk-juice at both baseline and 2-year follow-up [83].

Intervention studies

Only one intervention study has been conducted to assess SSB consumption and dental caries [89]. Maupomé et al. conducted community-wide interventions to reduce SSB consumption, improve breastfeeding practices, and promote consumption of water for thirst among American Indian toddlers. While the intervention communities demonstrated improvements in the number of dental caries, it is not possible to attribute this specifically to reduction in SSB consumption as the intervention was a multi-pronged approach.

Caffeine-related effects

A growing number of studies reported on the caffeine-related effects associated with SSB consumption with studies almost exclusively cross-sectional (Table 4).

Table 4.

Studies on caffeine-related effects associated with SSB consumption

Author, Year Setting Sample Size Sample Age Method of Diet Assessment SSB Unit of Analysis Primary Outcome Direction of Association Findings
Cross-Sectional Studies
Azagba, 2014 Adolescents attending public schools in Atlantic Canada 8210 Grades 7, 9, 10 and 12 Self-reported survey with question asking about consumption of caffeinated energy drinks in past year Energy drink more than once a month vs. one to two times Odds of depression, sensation seeking, substance use Positive Sensation Seeking
OR = 1.17 [95%CI: 1.11, 1.22]*
Depressive symptoms, very elevated
OR = 1.95 [95%CI: 1.36, 2.79]*
Depressive symptoms, somewhat elevated
OR = 1.08 [95%CI: 0.80, 1.47]
Cigarette use
OR = 2.58 [95%CI: 1.71, 3.89]*
Marijuana use
OR = 1.87 [95%CI: 1.37, 2.56]*
Alcohol use
OR = 2.48 [95%CI: 1.83, 3.36]*
Other drug use
OR = 1.80 [95%CI: 1.26, 2.57]*
Bashir, 2016 Convenience sample of patients in waiting areas of emergency department in U.S. 612 12-18 years Questionnaire asking about frequency of energy drink consumption Frequent (at least once a month) vs. Infrequent (less than once a month) consumers of energy drinks Proportion of frequent vs. infrequent consumers experience of headache, anger and increased urination Positive Headache
76% [95%CI: 69-81] vs. 60% [95%CI: 55-64]*
Anger
47% [95%CI: 40-54] vs. 32% [95%CI: 27-36]*
Increased urination
24 [95%CI: 18-30] vs. 13 [95%CI: 10-16]*
Study provides a number of outcomes. See paper for full results.
Koivusilta, 2016 Classroom survey of 7th grade students in Finland 9446 13 years Self-reported online survey asking about frequency of energy drink consumption Several times a day vs. not at all Odds of headache, sleeping problems, irritation, tiredness/fatigue, late bedtime Positive Headache
OR = 4.6 [95%CI: 2.8, 7.7]
Sleeping problems
OR = 3.6 [95%CI: 2.2, 5.8]
Irritation
OR= 4.1 [95%CI: 2.7, 6.1]
Tiredness/ fatigue
OR=3.7 [95%CI: 2.4, 5.7]
Late bedtime
OR = 7.9 [95%CI: 5.7, 10.9]
Kristjansson, 2013 School survey of children in Iceland 11,267 10-12 years Questions on population-based survey asking about frequency of energy drink and cola consumption ≥1 cola/day vs. none
≥1 energy drink/ day vs. none
Odds of headaches, stomachaches, sleeping problems, low appetite Positive Colas
Headaches
Females:
OR = 1.13 [95%CI: 0.87, 1.47]
Males:
OR = 1.29 [95%CI: 1.03, 1.62]*
Stomachaches
Females:
OR = 1.40 [95%CI: 1.08, 1.80]*
Males:
OR = 1.31 [95%CI: 1.03, 1.67]*
Sleeping problems
Females:
OR = 1.55 [95%CI: 1.21, 1.98]*
Males:
OR = 1.34 [95%CI: 1.09, 1.66]*
Low appetite
Females
OR = 1.37 [95%CI: 1.03, 1.83]*
Males
OR = 1.44 [95%CI: 1.12, 1.86]*
Energy Drinks
Headaches
Females:
OR = 1.68 [95%CI: 1.17, 2.41]*
Males:
OR = 1.87 [95%CI: 1.43, 2.46]*
Stomachaches
Females:
OR = 1.76 [95%CI: 1.21, 2.54]*
Males:
OR = 2.45 [95%CI: 1.86, 3.23]*
Sleeping problems
Females:
OR = 1.56 [95%CI: 1.07, 2.25]*
Males:
OR = 1.63 [95%CI: 1.25, 2.12]*
Low appetite
Females
OR = 2.31 [95%CI: 1.58, 3.39]*
Males
OR = 1.30 [95%CI: 0.95, 1.78]
Park, 2016 Nationally representative cohort of Korean adolescents 68,043 12-18 years Web-based survey with questions on energy drink consumption Highly frequent energy drink consumer (≥5 times/week) vs. infrequent energy drink consumer (<1 time/week)
Moderate frequent energy drink consumer (1-4 times/week) vs. infrequent energy drink consumer
Odds of sleep dissatisfaction, perceived stress, persistent depressive mood, suicidal ideation, suicide plan, suicide attempt Positive Highly frequent energy drink consumer vs. infrequent energy drink consumer
Sleep dissatisfaction
OR = 1.64 [95%CI 1.61, 1.67]*
Perceived stress
OR = 2.23 [95%CI: 2.19, 2.27]*
Depressive mood
2.59 [95%CI: 2.54, 2.65]*
Suicidal ideation
3.14 [95%CI: 3.07, 3.21]*
Suicidal plan
4.65 [95%CI: 4.53, 4.78]*
Suicide attempt
6.79 [95%CI: 6.59, 7.00]*
Moderate frequent energy drink consumer vs. infrequent energy drink consumer
Sleep dissatisfaction
OR = 1.25 [95%CI: 1.25, 1.26]*
Perceived stress
OR = 1.38 [95%CI: 1.37, 1.39]*
Depressive mood
OR=1.51 [95%CI: 1.49, 1.52]*
Suicidal ideation
OR=1.43 [95%CI: 1.42, 1.45]*
Suicidal plan
OR=1.78 [95%CI: 1.75, 1.81]*
Suicide attempt
OR=1.91 [95%CI: 1.87, 1.95]*
Richards, 2015 Adolescents from three secondary schools in the South West of England 2307 11-17 years DABS survey (assesses intake of common dietary variables), including questions on energy drink and cola consumption High consumption (≥1 can of energy drink or cola) vs. no consumption
Low consumption (<1 can of energy drink or cola) vs. no consumption
Odds of stress, anxiety and depression Mixed High consumption vs. no consumption
Energy Drinks
Stress
OR = 1.10 [95%CI: 0.80, 1.50]
Anxiety
OR = 1.05 [95%CI: 0.77, 1.43]
Depression
OR = 1.11 [95%CI: 0.81, 1.52]
Cola
Stress
OR = 0.68 [95%CI: 0.52, 0.90]*
Anxiety
0.83 [95%CI: 0.64, 1.09]
Depression
1.23 [95%CI: 0.93, 1.62]
Low consumption vs. no consumption
Energy Drinks
Stress
1.38 [95%CI: 1.05, 1.80]*
Anxiety
1.26 [95%CI: 0.97, 1.64]
Depression
0.99 [95%CI: 0.76, 1.31]
Cola
Stress
0.72 [95%CI: 0.56, 0.94]*
Anxiety
0.86 [95%CI: 0.67, 1.10]
Depression
1.18 [95%CI: 0.91, 1.54]
Longitudinal Studies
Marmorstein, 2016 Cohort of middle-school students in the U.S. 144 10-14 years, followed-up 16 months later Self-reported questionnaire with questions on energy drink consumption Energy drink consumption at baseline Change in ADHD inattention, ADHD hyperactive, conduct disorder, depression, panic, anxiety at follow-up (controlling for coffee) Mixed ADHD inattention
β = 0.20*
ADHD hyperactive
β = 0.20*
Conduct disorder
β = 0.18
Depression
β = 0.08
Panic
β = 0.17
Generalized anxiety
β = 0.09
Social Anxiety
β = -0.02

Note: * indicates statistical significance (p<0.05) as reported by each study

Cross sectional studies

A number of cross-sectional studies examined the effects of energy drink consumption among children and adolescents [9097], with each study often reporting on multiple outcomes. Some studies found evidence for an association between energy drink consumption and sleep-related issues such as sleep dissatisfaction, tiredness/fatigue and late bedtime [92, 93, 95], and others reported an association between energy drink intake and increased headaches [9193]. One study reported an association between energy drink consumption and risk-taking behaviors such as cigarette, marijuana and drug use [90], and two studies found an association between energy drink consumption and stress, depressive symptoms, and suicidal ideation, plan or attempt [90, 95]. Other outcomes examined in these cross-sectional studies reported include irritation [92], stomach ache and low appetite [93].

Some of the cross-sectional studies examined caffeine-related effects of cola drinks [93, 96, 97]. One found that both low and high consumption of cola were associated with lower stress and found null associations with anxiety and depression [96]. Another examined both cola and energy drinks and found that higher consumption of both beverages was associated with headaches, stomach-aches, sleeping problems and low appetite [93]. More specifically, among males, drinking more than one cola per day was associated with a 1.34 greater odds of sleeping problems and among females drinking more than one cola per day was associated with a 1.55 greater odds of sleeping problems.

Longitudinal studies

One longitudinal study was conducted and it found evidence that increased energy drink consumption was associated with attention deficit/hyperactivity disorder inattention and hyperactivity at 16-month follow-up, but did not find evidence for associations with depression, panic and anxiety [94].

Summary of evidence

Since the most recent relevant review was published on this topic in 2009 [16], there has been a substantial increase in research examining the health consequences of SSB consumption among children and adolescents. For example, 227 studies indexed in PubMed were published on SSBs in 2017 compared to 16 studies published in 2007.1 Many more studies are now conducted exclusively on children and adolescents, while previous evidence was based on results found among adults. While the majority of this research is still cross-sectional (limiting the ability to make inferences about causality), the past decade has seen a growing number of longitudinal studies being implemented, as well as an increasing amount of intervention trials.

The majority of this research on SSBs over the past decade has centered on the relationship with weight gain. The findings of this review confirm that there is clear and consistent evidence that the consumption of SSBs heightens obesity risk among children and adolescents. Although a formal quality assessment or strength of evidence evaluation was not conducted, the vast majority of cross-sectional, longitudinal and intervention studies find strong evidence for a positive relationship in all or part of their study population. The exact mechanism through which SSBs impact childhood obesity is not entirely understood. Generally, the research points to the low satiety of SSBs and incomplete compensation [98, 99]. In other words, drinking calories in liquid form does not decrease hunger in the same way as solid food. Additionally, people do not sufficiently reduce their total energy intake to make up for the excess calories obtained from SSBs. There is also a lively debate about whether the effect of calories from SSBs on body weight is worse than some other foods or nutrients [100, 101].

The association between SSB consumption and weight gain is paramount, given that childhood obesity affects roughly one in six (13 million) children in the U.S., disproportionately impacting children who are low-income and racial and ethnic minorities [102]. From 1976 to 2016, the prevalence of childhood obesity in the U.S. more than doubled in children ages 2 to 5 (from 5% to 13.9%), nearly tripled in children aged 6 to 11 (from 6.5% to 18.4%) and quadrupled in adolescents’ ages 12 to 19 (from 5% to 20.6%) [103105]. While there is some indication that childhood obesity rates may leveling in the U.S. [104], the overall prevalence of obesity among children in 2016–2016 was estimated at 18.5% [105], meaning it is still considerably higher than the Healthy People 2020 goal of 14.5% [4]. Given that children who are overweight and obese youth are likely to remain so as adults [106], obesity and its adverse health consequences create a serious threat to children’s current and future health [107]. Hence, reducing SSB consumption is an important intervention point to reduce the burden of childhood obesity in the U.S.

This review also finds strong and consistent evidence that consumption of SSBs is associated with dental caries among children and adolescents. The mechanism for the association between SSB consumption and dental caries is well understood: dental caries are caused by acids produced by bacteria metabolizing sugar in the mouth. Increased sugar from SSBs intensifies the acid production and causes further decay of teeth [108]. The majority of studies examining this relationship are cross-sectional, but a modest number of longitudinal studies as well as one intervention study also support the association.

While evidence has shown a positive relationship between SSB consumption and type 2 diabetes among adults [5, 12, 109], the available literature among child and adolescents is limited. The majority of studies among children and adolescents do not directly examine the link between SSB consumption and type 2 diabetes and instead measure insulin resistance, a biomarker of increased cardio-metabolic risk and type 2 diabetes. It is hypothesized that the high content of sucrose and high-fructose corn syrup present in SSBs may increase dietary glycemic load leading to insulin resistance and inflammation [7]. While not as strong and consistent as the relationships between SSB consumption and weight gain or dental caries, most studies in this review generally support an association between SSB consumption and insulin resistance among children and adolescents. However, this is limited by a small number of studies and the predominance of a cross-sectional study design.

The findings of this review also point to an association between caffeinated SSBs and a wide range of health issues including poor quality or reduced sleep, headaches, risk-seeking behavior and depressive symptoms. The presence of caffeine in energy drinks and other caffeinated SSBs (e.g., cola), in conjunction with the large volumes consumed, can lead to neurological and psychological effects associated with high caffeine consumption. The majority of studies examining the caffeine-related effects of SSBs focus on energy drinks, with very few analyzing the effects of other caffeinated SSBs such as colas. One reason for this may be the considerably higher level of caffeine content in energy drinks: a 250 mL energy drink has an average of 80 mg of caffeine (range: 27-87 mg), compared to 40 g of caffeine (range: 30-60 mg) in a 330 mL cola drink [110]. Additionally, studies examining caffeine-related effects have almost exclusively been cross-sectional, limiting the strength of inferences that can be made and bringing forth issues of reverse causation.

While there is a large and growing body of research examining the impact of SSBs on children’s health, important gaps remain. First, researchers should utilize more rigorous study designs (intervention trials and longitudinal studies) and move away from a reliance on cross-sectional studies. This will strengthen the evidence base and allow firmer conclusions to be made regarding the causal relationships between SSB consumption and negative health consequences. Second, more consistency is needed in the definition of SSBs (e.g., specifying which beverages are included and what is a typical serving size) and measurement strategy (e.g., FFQ vs. 24-h recall). Similarly, more uniformity is needed in assessing outcomes, particularly in the risk of overweight/obesity where studies vary considerably in the outcomes measured (e.g., BMI, BMI z-score, BMI percentile, overweight/obese status). Third, researchers should more rigorously examine differences in health risks by subpopulations (e.g., race/ethnicity, socioeconomic status, age and gender) to determine if the intake of SSBs in particularly harmful in certain population subsets. While it is established that low-income and racial and ethnic minorities consume more SSBs, it is unclear the extent to which health consequences are magnified among these groups. This is important particularly for targeting interventions and policy approaches to reduce children’s SSB consumption. Better insights in these areas have the potential to inform real-world policies and recommendations that may greatly benefit children’s health. Finally, additional research is needed about caffeinated SSBs and their impact on children’s health. Energy and sport drink consumption is rising rapidly in the U.S. [13] and so studies examining the negative health effects of caffeinated SSBs are needed to inform future efforts to reduce consumption.

This review has several limitations. First, it only focuses on four main health effects associated with SSB consumption and does not address other potential consequences which have been documented among consumers of SSBs (e.g., hyperlipidemia, non-alcoholic fatty liver disease). Second, our conclusions for a particular health consequence did not include a quality assessment and was limited to an informal evaluation of consistency and lack of conflicting studies. Third, article screening was not done in duplicate, although all included articles were confirmed by a second reviewer.

Conclusion

This review provides clear and consistent evidence that consumption of SSBs increases obesity risk and dental caries among children and adolescents, with emerging evidence supporting an association with insulin resistance and caffeine-related effects. In general, the strength of evidence for all four health consequences could be improved through the implementation of more longitudinal and intervention studies. Additionally, more consistency is needed from studies in the measurement of exposures (e.g., standardized measurement and definition of SSBs) and outcomes (e.g., assessment of weight-related outcomes) to create a stronger evidence base. Future research should compare low-income and racial/ethnic minority subgroups in order to determine if differences in health risks associated with SSBs exist. Although SSB consumption has declined in the last 15 years, consumption still remains high (61% of children consume at least one SSB per day). The vast majority of the available literature suggests that reducing SSB consumption would improve children’s health.

Additional file

Additional file 1: Appendix. (128.4KB, docx)

Search Strategies (Contains the full list of search terms and PRISMA diagrams). (DOCX 128 kb)

Acknowledgements

Not applicable

Funding

This work was funded by the Robert Wood Johnson Foundation Healthy Eating Research Program.

Availability of data and materials

Please contact author for data requests.

Abbreviations

BMI

Body mass index

NHANES

National Health and Nutritional Examination Survey

OECD

Organisation for Economic Co-operation and Development

SSB

Sugar-sweetened beverage

Authors’ contributions

SNB designed the research. KAV conducted the review. SNB and KAV drafted and revised the paper for intellectual content. SNB had primary responsibility for final content. Both authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Footnotes

1

Author calculations, based on PubMed results by year.

Electronic supplementary material

The online version of this article (10.1186/s40608-017-0178-9) contains supplementary material, which is available to authorized users.

Contributor Information

Sara N. Bleich, Phone: 617.432.0217, Email: sbleich@hsph.harvard.edu

Kelsey A. Vercammen, Email: kev266@mail.harvard.edu

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Associated Data

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Supplementary Materials

Additional file 1: Appendix. (128.4KB, docx)

Search Strategies (Contains the full list of search terms and PRISMA diagrams). (DOCX 128 kb)

Data Availability Statement

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