Tag Archive for: fruit juice

Bottoms Up!

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As we approach the holiday season, do we have to skip the fruit juice punch or the pumpkin spice lattes? How about eggnog? Let’s take a look at the study on the risks of various drinks, and determine the relevance and the practical risk of what you drink.

Does What You Drink Really Matter?

Here are some of the issues I found with the study.

The data used a food frequency questionnaire as well as additional surveys to collect all the data. I’ve talked enough about the problems with the food frequency questionnaire, and the INTERSTROKE Study didn’t use any better techniques.

In prior papers from the INTERSTROKE study, the researchers identified 10 risk factors that accounted for 90.7% of the Population Attributable Risk (PAR) worldwide for a first-time stroke. The PAR together with the percentage contribution of each factor is as follows:

  • Prior history of hypertension or blood pressure of 140/90 or higher: 47.9%
  • Lack of regular physical activity: 35.8%
  • Apolipoprotein (ApoB) to ApoA1 ratio: 26.8%
  • Diet assessed by the modified Alternative Healthy Eating Index: 23.2%
  • Waist-to-hip ratio: 18.6%
  • Psychosocial factors: 17.4%
  • Current smoking: 12.4%
  • Cardiac causes: 9.1%
  • Alcohol consumption: 5.8%
  • Diabetes mellitus: 3.9%

What a person drinks would be a small contributor to the diet assessment. It’s legitimate, but there are bigger issues in my opinion.

Finally, looking at the actual risk of stroke in the U.S. and Canada, it’s 0.9% if you’re 18–44 years old, it’s 3.8% at 45–64 yrs, and it’s 7.8% if you’re over 65. That’s the risk without modifying any risk factors in the PAR. What a person drinks would be a very small contributor to that risk. I think working on BP and exercise first makes a lot more sense.

The Bottom Line

Does what you drink matter? Unless you overconsume alcohol, probably not. Could you help yourself out? Yes. Drink seven or more cups of water per day—that’s just 60 ounces—and enjoy a cup or two of any type of tea per day; if you like iced tea, try Paula’s recipe on our website. And if all you’ve ever had is black tea, you need to branch out and try some more exotic varieties. Both water and tea lowered the odds ratio of a first stroke.

Other than that, try to strike a balance with what you drink. Spend more time getting your BP under control, and one of the ways to do that is to exercise. This is as good a time as any to begin. I know you can do it.

What are you prepared to do today?

        Dr. Chet

References:
1. International Journal of Stroke 2024, Vol. 19(9) 1053–1063.
2. Journal of Stroke 2024;26(3):391-402.
3. Lancet 2016 Aug 20;388(10046):761-75.
4. MMWR. May 23, 2024. 73(20);449–455.

What Am I Supposed to Drink?

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Why would someone ask that question? It was in response to a health news report on a couple of studies that suggested that if you drink too much fruit juice, any soda at all, or five or more cups of coffee, you’ll have an increased risk of a first stroke. Let’s take a look at the studies to see if we should change any of our drinking habits.

Based on the methodology, cases of first stroke were recruited from 142 centers in 32 countries between March 2007 and July 2015; at the same time, they recruited matched controls who did not have a stroke. They ended up with 13,462 subjects with stroke and 13,488 controls that did not have strokes. The mean age was close to 62 +/- 13 years. Besides biometric data including neural imaging, the researchers used a variety of surveys including food frequency questionnaires to determine all fluid intake.

After accounting for 15 potential factors that might skew the data, researchers calculated the odds ratios for water, soda, fruit juice, coffee, and tea intake. Teas of all types reduced the odds ratio for stroke, as did drinking seven or more cups of water per day. Any soda, fruit juice, or five or more cups of coffee per day raised the odds ratio, almost doubling the risk of a first stroke.

Should we be concerned? Let’s take a closer look at what this study really means on Saturday.

What are you prepared to do today?

        Dr. Chet

References:
1. International Journal of Stroke 2024, Vol. 19(9) 1053–1063.
2. Journal of Stroke 2024;26(3):391-402.

The Bottom Line on Sugary Drinks and Cancer

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The question is simple: do we avoid all sugary drinks, including fruit juices? The best I can come up with is to withhold judgment and don’t get excited about it for now. Let’s take a look at what the concerns of the researchers were and then my concerns.

Researchers’ Concerns

The first is that the NutriNet-Santé study was not a randomized sample. That means that only those people who were interested in participating for whatever reason did so. The sample was predominantly women at 78.7% of the cohort with a mean age of 42 years. The researchers accounted for age and gender in the statistical analyses, but that doesn’t account for the lack of randomization.

Researchers also stated that the rate of cancer was much lower: 620 of the 100,000 people in the study compared with 972 per 100,000 people in all of France. They adjusted the numbers to reflect the age and gender distribution in France, but I used the numbers actually given in the study. They also said the diagnosis of cancer was self-reported. I can’t believe anyone would say they have cancer if they don’t, but it would have been better if it were verified.

Related to that, some cancers were limited, thus affecting the statistics. If you don’t have enough of any type of cancer, it’s difficult and scientifically shaky to calculate a relationship.

Younger subjects consumed higher amounts of sugary drinks than older subjects. There were other factors as well, but these also were taken care of statistically. Further, they acknowledge what I alluded to: when people self-report, they can over- and under-estimate their intake. They also chose only the subjects that had at least two diet records completed in the first two years; the potential was 10 if all records were completed by all subjects. That seems low to me—there’s too much missing data.

Finally, this was an observational study and thus cause and effect can’t be attributed to the results. But it does raise questions.

My Questions

I think they could have gone a long way to answering the question about sugar intake if they had compared the fruit intake with the juice intake: take the fruit intake, calculate the sugar content, then match it with juice intake with the same sugar content. What was the rate of cancer in each group? Doing the direct comparison could go a long way to suggest whether it’s the sugar alone or if the effects were ameliorated with the fiber and phytonutrients of whole fruit with the same amount of sugar. That’s an obvious question; this is an ongoing study so maybe they’ll do that in the future.

I also think that running a comparison of total carbohydrate intake could also give us insight. If someone had a high carbohydrate intake, especially if it were high in refined carbohydrates, that might be meaningful as well.

The Bottom Line

The question I was left with was this: how could less than a half-cup per day of any type of added sugary drink that contained fewer than 50 sugar calories cause an increase in cancer? It just doesn’t make any kind of sense when you consider the total mean average calorie intake of the subjects was 1,850 calories. If the total sugar intake from solid foods of the individuals was high, or it was highly refined carbohydrates, that could make a difference. That analysis wasn’t done.

At this point, I wouldn’t stop drinking a glass of fruit juice or adding some juice to a smoothie. Don’t go out of your way to drink more fruit juice, but don’t avoid it either; certainly you should choose fruit juice from whole fruit over soda with sugar. If you have an artificial sweetener you like, use that instead of sugar. As for other drinks that contain sugar, they’re highly refined carbohydrates so you should be keeping those under control anyway. While this was an interesting and controversial report, nutrition is still about balance. Keep that in mind as you choose what you eat and drink every day.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

Finding the Cancer Risk in Sugary Drinks

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In Tuesday’s Memo, I reviewed the methodology of the NutriNet-Santé study in France. As I suggested, it was solid. The sugary drink choices included fruit juices, sodas, sugar-sweetened hot and milk beverages, sports drinks, and energy drinks. In terms of the data collection, I can’t think of anything they could have done better.

Turning to the statistical analysis, it was complicated to say the least. The use of high-speed computers allows for many statistical analyses to be done in short order, even with over 100,000 subjects. My only concern is that, as they did the trend for hazard ratios, they adjusted for many variables including age, gender, energy intake, and family history. How many variables? About 24 in all by my count. That’s not necessarily wrong, but there are some that would seem obvious such as total carbohydrate intake from all foods, and percentage of calories from carbohydrates other than vegetables and fruit.

Another way of analyzing the data was something I’ve done before, and that’s compare the rate of cancer to the national cancer statistics in France. In this case, the rate of cancer in France is 0.95% while it was 0.87% in the unadjusted data from the study. That’s very close and a bit lower than the national average.

Must we avoid even a half-cup of fruit juice per day? Is the sugar in your coffee or sweet tea causing a significant increase in your risk of getting cancer? I’ll let you know on Saturday.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.

Is There a Link Between Sugar and Cancer?

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Sugar has been in the news with the publishing of the latest results from the NutriNet-Santé study from France. The headlines of press releases suggest that drinking as little as four ounces of a sugary drink, including fruit juice, per day was related to an increased risk of getting cancer. Sugary drinks of all types except fruit juice were associated with an increased risk of getting breast cancer. These were all hazard ratio trend analyses; as the consumption increased, so did the risk of cancer.

If you read the Memos regularly, you know my approach is to always check how the data were collected. In this study, they used three 24-hour dietary records that included two weekdays and one weekend day. The diet records were done every six months throughout the duration of the follow-up, about five years. They subjects entered their data online; with over 100,000 subjects, that’s the only way this study could be done.

Of all the types of diet assessments, this is as close to the gold standard as I’ve seen. They had 97 different sugary drinks and 12 artificially sweetened drinks that were possible choices with very detailed descriptions and photos of drinks to help assess portion size. The only step they didn’t take was to have the records checked by a dietician before the subjects entered their data online. The methods in this study were solid compared to just about every other study I’ve talked about.

Should we avoid all sugary drinks at this point? More on Thursday. Tomorrow is the July Insider Conference call; this is your chance to learn more about nutrition and get your questions answers. You can still be included, so check out memberships right now.

What are you prepared to do today?

        Dr. Chet

Reference: BMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l2408.