Practice Update: DIABETES

OBESITY 17

Artificially sweetened beverages, stroke and dementia Stroke; A Journal of Cerebral Circulation Take-home message

sweetened beverage consumption was associ- ated with the prospective risks of incident stroke or dementia in the community-based Framing- ham Heart Study Offspring cohort. METHODS We studied 2888 participants aged >45 years for incident stroke (mean age 62 [SD, 9] years; 45% men) and 1484 participants aged >60 years for incident dementia (mean age 69 [SD, 6] years; 46% men). Beverage intake was quantified using a food-frequency questionnaire at cohort examinations 5 (1991–1995), 6 (1995– 1998), and 7 (1998–2001). We quantified recent consumption at examination 7 and cumulative consumption by averaging across examinations. Surveillance for incident events commenced at examination 7 and continued for 10 years. We observed 97 cases of incident stroke (82 ischemic) and 81 cases of incident dementia (63 consistent with Alzheimer’s disease). RESULTS After adjustments for age, sex, educa- tion (for analysis of dementia), caloric intake, diet quality, physical activity, and smoking, higher recent and higher cumulative intake of artificially sweetened soft drinks were associated with This study should not be taken as sug- gesting that sugar-sweetened beverages are okay. We know that too much sugar is associated with many negative outcomes, including obesity, dysbiosis, and meta- bolic dysfunction. But the study should lend some caution as to the safety of arti- ficial sweeteners. One that has had the most controversy is aspartame. Aspartame is composed of 50% phenylala- nine, 40% aspartic acid, and 10%methanol. One of several potentially toxic byproducts of aspartame is formaldehyde. Humphries et al summarized the potential cellular mechanisms aspartame has on the brain in the European Journal of Clinical Nutrition . 1 They state that aspartame disturbs integ- rity of neuronal function, causes nerves to fire excessively, depletes ATP function in mitochondria, and causes dysfunction of the endothelium, leading to a compro- mised blood–brain barrier. The literature has mentioned concern for aspartame in relation to headaches, malignancies, and learning disabilities.

• The association between sugar- and artificially sweetened drink intake and risk for stroke or dementia was evaluated in the Framingham Heart StudyOffspring cohort. After adjusting for multiple confounders, both recent intake and cumulative intake of artificially sweetened drinks were associated with significantly greater risks for ischemic stroke anddementia. • Similar associations were not found for sugar-sweetened drinks. Abstract BACKGROUND AND PURPOSE Sugar- and artificial- ly-sweetened beverage intake have been linked to cardiometabolic risk factors, which increase the risk of cerebrovascular disease and demen- tia. We examined whether sugar- or artificially

an increased risk of ischemic stroke, all-cause dementia, and Alzheimer’s disease dementia. When comparing daily cumulative intake to 0 per week (reference), the hazard ratios were 2.96 (95% confidence interval, 1.26–6.97) for ischemic stroke and 2.89 (95% confidence interval, 1.18–7.07) for Alzheimer’s disease. Sug- ar-sweetened beverages were not associated with stroke or dementia. CONCLUSIONS Artificially sweetened soft drink consumption was associated with a higher risk of stroke and dementia. Sugar- and artificially sweetened beverages and the risks of incident stroke and dementia: a prospective cohort study. Stroke 2017 Apr 20;[EPub Ahead of Print], MP Pase, JJ Himali, AS Beiser, et al. This was an observational study and thus causation cannot be made. An additional caveat to keep in mind when interpreting the results of this study is that partici- pants with diabetes, who are more likely to develop stroke and dementia, also consumed more artificially sweetened beverages. While the authors adjusted for diabetes in supplementary analyses, it is likely that residual confounding in both primary and supplementary analyses has not been eliminated. But this study is a reminder that nature is smarter than we are. We are likely better off eating whole foods artfully combined by a good chef than a processed food put together by a biochemist. Reference 1. Humphries P, Pretorius E, Naude H. Eur J Clin Nutr 2008;62(4):451-462.

COMMENT By David Rakel MD, FAAFP “As for butter versus margarine, I trust cows more than chemists.” T his quote by nutritionist Joan Dye Gussow supports how our manipu- lation of nature can get us in trouble.

Last week, we reviewed how banning trans-fatty acids (a product of chemists, not nature) resulted in fewer heart attacks in New York. This week, we can see how artificial sweeteners in soda (also made by chemists) are associated with high risk of stroke (HR, 2.96) and dementia (HR, 2.89). This association was not seen with sug- ar-sweetened drinks.

0/week

>0–6/week

Dr Rakel is Professor and Chair of the Department of Family & Community Medicine, University of New Mexico School of Medicine, New Mexico.

Stroke-free survival

≥1/Day

Cumulative consumption of artificially sweetened soft drinks

1

5 Years

10

VOL. 1 • NO. 1 • 2017