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Sugar-sweetened beverage intakes among adults between 1990 and 2018 in 185 countries

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Thank you for visiting nature. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser or turn off compatibility mode in Internet Explorer. In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript. Sugar-sweetened beverages SSBs are associated with cardiometabolic diseases and social inequities. For most nations, recent estimates and trends of intake are not available; nor variation by education or urbanicity. In , mean global SSB intake was 2. Intakes were higher in male vs. Variations by education and urbanicity were largest in Sub-Saharan Africa. These findings inform intervention, surveillance, and policy actions worldwide, highlighting the growing problem of SSBs for public health in Sub-Saharan Africa. What people eat and drink is one of the most important determinants of health as well as health equity 1. Most of these diet-related health burdens were due to cardiometabolic diseases, including cardiovascular disease CVD , type 2 diabetes T2D , and cancer. These diet-related conditions not only reduce quality of life and productivity but are also leading risk factors for worse clinical outcomes from COVID 3. Therefore, improving diets to reduce deaths, complications, and economic and equity burdens from cardiometabolic diseases should be a global priority. Sugar-sweetened beverages SSBs are a priority concern given their relationship with obesity, CVD, T2D, cancer, and dental caries 4 , 5 , 6 ; absence of any offsetting nutritional benefits 7 ; intensive marketing to traditionally marginalized populations 8 ; and contribution to health disparities 9. Yet, for the vast majority of nations, recent national estimates of SSB intake are unavailable, preventing an analysis of the evolving and potentially nonlinear trends in intake in recent decades. Furthermore, prior global estimates have not evaluated SSB intake subnationally by important sociodemographic factors such as education or urbanicity. This lack of evidence limits the ability to design and measure the impact of interventions aimed at decreasing SSB intake, as well as the capacity to identify populations where such interventions are needed the most. In an investigation based on data, , global deaths were estimated to be attributable to SSB intake, including Since that time, national and subnational dietary data from a handful of high-income nations suggest that SSB intake has decreased in selected high-income Western countries 10 , 11 , 12 , 13 , 14 , 15 and Brazil However, energy contribution from SSBs remains high in these nations; and SSB intake may be increasing, based on limited national intake and sales reports, in non-Western countries such as Korea 17 and India More recent, harmonized, and subnationally stratified data on SSB intakes are needed to inform intervention, surveillance, and policy actions. In this work, we show that intakes were higher in male vs. These new findings on global SSB intakes, trends, and inequities inform intervention, surveillance, and policy actions worldwide, highlighting the growing problem of SSBs for public health in Sub-Saharan Africa. In , the mean global intake of SSBs among adults was 2. Among the 25 most populous countries worldwide, the highest intakes were in Mexico 8. Of countries, 58 The analysis of the data was done using the rworldmap package v1. Source data are provided as Source Data file 1. Oz ounces, SSBs sugar-sweetened beverages. Globally, regionally, and nationally, males had modestly higher energy-adjusted SSB intake than females Table 1 , Supplementary Table 6. By age, SSB intakes were higher at younger vs. In contrast, in South Asia, where intakes were the lowest across all regions, intakes were 1. Regionally, patterns of intake by age were similar between males and females Supplementary Fig. Among the 25 most populous countries, the highest intakes were among adults age 20—39 years from Mexico Source data are provided as Source Data file 2. Globally, SSB intakes varied substantially by region and education. Intakes were higher among more vs. Differences by high vs. By urbanicity, the largest differences by education were among urban and rural adults in Sub-Saharan Africa Fig. Source data are provided as Source Data file 3. Among the 25 most populous countries, the largest differences in SSB intake in high vs. By urbanicity, global intakes were Differences by urbanicity decreased as age increased in all regions, with largest differences in urban vs. Among the 25 most populous countries, largest differences by urbanicity were in Pakistan, Nigeria, and Ethiopia, where adults from urban vs. Source data are provided as Source Data file 4. Globally, intakes were higher in urban vs. Stratified by both education and area of residence, globally, urban adults had higher intakes than rural adults at all education levels Fig. However, by region, this pattern was only observed in Sub-Saharan Africa and South Asia, was not notable in most other regions, and was reversed higher intakes in rural vs. Values were truncated at Strikingly, assessing both education and urbanicity by region, the highest intakes globally were among highly educated adults from urban Sub-Saharan Africa However, regional changes were highly heterogenous. Other world regions had more modest, steady increases over time. Values in b were truncated at 3. Source data are provided as Source Data files 2 and 6. Energy-adjusted SSB intakes and trends were generally similar in males vs. By age, globally, and in most regions, SSB intake increased across all age groups in both time periods. However, trends by urbanicity were highly heterogeneous across world regions, with larger increases in urban vs. Trends over time by age, sex, education, and urbanicity within the 25 most populous countries are in Supplementary Discussion 1 and Supplementary Tables 15 — Values were truncated at 5. Source data are provided as Source Data files 1 and 7. Person correlation was assessed between SDI and SSB intakes among a total of countries were included in this analysis. Source data are provided as Source Data File 1. This analysis, based on new GDD estimates which incorporate data on mostly national, individual-level dietary surveys, provides estimates of SSB intakes and trends between and globally, regionally, and nationally. In addition to updating previous estimates stratified by sex and age with additional surveys, modeling methods, and follow-up time 19 , we provide further estimates stratified by educational attainment and urbanicity. SSB intake is associated with a higher risk of obesity, CVD, T2D, cancer, and dental caries 4 , 5 , 6 , imposing important health and economic burdens. Increasing trends were more pronounced in specific subnational groups, and with varying patterns in these groups by world region. Trends were not notably different between males and females globally or regionally. The SDI findings highlight cross-national inequities in intakes, showing that higher national social and economic development is statistically significantly correlated with lower SSB intakes. These findings are in line with the ongoing nutrition and epidemiologic transition globally, disproportionally affecting the poorest nations Moreover, they indicate a need to accelerate strategies aimed at decreasing SSB intake to tackle this global health problem, focusing on key population groups within each specific world region. Nevertheless, many of these efforts have been blunted by strong food industry opposition techniques including disqualification of research findings, biased industry-funded research, misleading summaries, marketing techniques, and false claims on the potential adverse social consequences such as massive job losses 25 , Future surveillance of SSB intakes globally is needed to determine the relative impact of these and other policies on SSB intakes such as reformulation , both across nations and for subgroups within each nation. With its economic growth and increasing middle class, Sub-Saharan Africa has become an appealing target for industry marketing of SSBs Despite evidence for the effectiveness of SSB taxes in South Africa, such measures have not been implemented in other countries in the region, limited by a lack of credible country-specific data and indicators on SSB intake to support the design, implementation, monitoring, and evaluation of taxation The findings from our study may help inform SSB-related policies in these and other countries that may be lacking valid intake estimates. In addition, we found that SSB intakes in Sub-Saharan Africa among younger, more educated, and urban adults were among the highest in the world; and that these differences by socioeconomic characteristics were also more pronounced than in other regions. These results suggest that SSB policies directed at specific subgroups could have a large impact, supporting a more strategic allocation of limited public health resources in these nations. Our findings further suggest no major differences by education level or area of residence, emphasizing the need for implementing broad policies to decrease SSBs across the general population. In recent years, several countries in this region have implemented policies targeting SSBs, including taxes, marketing restrictions, front-of-package warning labels, and education campaigns While SSBs taxes are recommended as one of the most effective measures 24 , 31 , 32 , only Chile , Mexico , Dominica , Barbados , Ecuador , Peru , Bermuda , and Panama , have implemented this policy Supplementary Data 3 National sales analyses suggest moderate decreases in SSBs and increases in alternative beverages following implementation. In Mexico, for instance, SSB purchases decreased by 8. In Chile, household SSB purchases declined by 3. Based on these successful but modest decreases, researchers and public health experts have advocated for higher tax rates and implementation across other nations to further impact SSB intakes Most national measures to reduce SSB intakes have occurred relatively recently, limiting their impact during the period of our investigation. In Latin America, for example, regulations on the advertising of SSBs have been implemented in Brazil , Mexico , Peru , and Chile ; evidence on the impact of these measures remains limited, particularly for adults 30 , In Chile, an observational study of beverage purchases found that from to the purchase volume of SSBs decreased by The findings from our study demonstrating high intakes in this region add to the evidence that additional policies are needed aimed at decreasing SSBs. Given that most national SSB policies have been recently implemented, further surveillance in this region is essential to understand the effects of these programs, especially among population subgroups with the highest intakes. Our findings provide a foundation for future time-series analyses, carefully adjusted for other factors, to assess how these and other SSB-directed policies may relate to changes in within-country SSB intake over time. A few national studies using mostly hour recalls or food records found slightly lower estimates than GDD 36 , Our findings might differ from estimates from sales data. Home-sweetened teas and coffees were not explicitly excluded from the SSBs definition when data was requested from data owners. However, these were most likely excluded by the data owners in the majority of the cases given that tea and coffee were collected as separate variables within the same data request. Global dietary surveys generally do not collect information on sweetened tea or coffee, and even sales data on ready-to-drink tea and coffee is limited. Therefore, by excluding these products we enhance comparability across countries and findings from other reports. Furthermore, sales data suggest that ready-to-drink RTD tea consumption was relatively modest in Asia in 0. Thus, the inclusion of these teas would not substantially alter our results. However, the Asian market for RTD teas, along with coffees, is expanding, and future surveillance and monitoring of the intake is needed to keep pace with this evolving category. Therefore, these were excluded from our definition of SSBs, which focuses on beverages with added sugar. Our definition may have missed beverages with lower sugar content, but the vast majority were captured. As a result, our definition encompasses all usual SSBs and even some with less sugar than average. Our findings on high intakes of SSBs and increases over time across most regions, support the global actions aimed at decreasing the intake of SSBs such as taxes. Moreover, this highlights the need to target all sugar-containing beverages, including sweetened teas and milk, to prevent substitution with these beverages. Our study has several strengths. To our knowledge, our investigation is the first to assess and report global, regional, and national estimates of SSB intakes jointly stratified by age, sex, education, and urbanicity. Compared to previous estimates, our current model included a larger number of dietary surveys, additional demographic subgroups, and years of assessment. Updated Bayesian hierarchical models better incorporated survey and country-level covariates; assessed time trends; and addressed heterogeneity, missingness, and sampling and modeling uncertainty. Intakes were estimated from surveys, mostly nationally or subnationally representative, collected at the individual-level, and representing Other recent estimates of global SSBs relied mostly on national per capita estimates of food availability e. FAO food balance sheets or sales data Such findings can substantially misestimate intake compared to individual-level data 42 and are less robust for characterizing differences across population subgroups. Finally, our findings are consistent with individual national reports 45 , such as in Mexico where urban vs. Even with systematic searches for all relevant surveys, we identified limited availability for several countries particularly lower-income nations and time periods Thus, estimated findings in countries with no primary individual-level surveys have higher corresponding uncertainty, informing surveillance needs to assess SSBs nationally and in subnational populations. All types of dietary assessments include some error, whether from individual-level surveys, national food availability estimates, or other sources. For instance, self-reported data relies on the memory and personal biases of the respondents, thus introducing potential bias in their responses by under or overreporting their actual intakes. Furthermore, assumptions relating to standardization of serving sizes, SSB definitions, energy adjustment, and household-level disaggregation, as well as of no interaction between sociodemographic variables in our model, could have impacted our estimates. We decided not to include interaction terms between various demographic variables to preserve model stability. Overall, our findings should be taken as the best currently available, but still imperfect, estimates of SSB intake worldwide. Our findings also provide evidence on national and subnational SSB intakes, trends over time, and related nutritional inequities, helping to inform the need and design of national and more targeted policies and approaches to reduce SSB intake worldwide, highlighting the growing problem of SSBs for public health in Sub-Saharan Africa. Data informing the GDD modeling estimates for this study, including from LMICs, were collected between and in the form of dietary intake surveys. If nationally representative surveys were not available for a country, we also considered national surveys without representative sampling, followed by regional, urban, or rural surveys, and finally large local cohorts, provided that selection and measurement biases were not apparent limitations. For countries with no surveys identified, other sources of potential data were considered, including the WHO Infobase, the STEP database, and household budget survey data. As of August , we identified and retrieved eligible survey years of data from public and private sources. Of these, have been checked, standardized, and approved for GDD model inclusion, of which surveys inform the SSB intake estimates. Most identified data were either privately held or not in a format appropriate for our modeling. We thus relied almost entirely on direct author contacts in each country to provide us with exposure data directly. The roles and responsibilities of GDD Consortium members were determined and agreed upon before data sharing as part of a standardized data-sharing agreement. The draft manuscript was shared with all GDD consortium members before submission for peer review, and all members have been included as authors of this work. This research is locally relevant to all countries included, given that it disaggregates findings nationally and subnationally by key demographic factors such as age, sex, education level, and urbanicity, providing decision-makers with stratum-specific SSB intake data and trends over time. This investigation was exempt from ethical review board approval because it was based on published de-identified nationally representative data, without personally identifiable information. Individual surveys underwent ethical review board approval required for the applicable local context. The GDD is an international collaborative effort to produce comprehensive and comparable estimates of dietary intakes of major foods and nutrients in countries. Details on the methods and standardized data-collection protocol have been described previously and are also explained below 19 , 48 , 49 , 50 , 51 , 52 , Compared to GDD , innovations include a major expansion of individual-level dietary surveys and global coverage through ; inclusion of updated data jointly stratified subnationally by age, sex, education level, and urban or rural residence; and updated modeling methods, covariates, and validation to improve estimates of stratum-specific mean intakes and uncertainty. The approach and results of our survey search strategy by dietary factor, time, and region have been detailed elsewhere Briefly, we performed systematic online searches for individual-level dietary surveys in countries globally, as well as extensive personal communications with researchers and government authorities throughout the world, inviting them to be corresponding members of the GDD. Surveys were prioritized if nationally or subnationally representative and using individual-level dietary assessments with standardized hour recalls, food frequency questionnaires, or short standardized questionnaires e. When national or subnational individual-level surveys were not identified for a country, we searched for individual-level surveys from large cohorts, the WHO Global Infobase, and the WHO Stepwise Approach to Surveillance database. Household budget surveys were used when individual-level dietary surveys were not identified for a particular country. We excluded surveys focused on special populations e. The final GDD model incorporated dietary surveys representing countries and Of these, surveys reported data on SSBs, totaling 2. Most surveys were nationally or subnationally representative The total sample size included Further details on survey characteristics are in Supplementary Data 1. For each survey, we extracted data using standardized methods on survey characteristics and dietary metrics, units, mean, and standard deviation of intake, by age, sex, education level, and urban or rural residence 52 , The sociodemographic characteristics were used as reported by each survey, and details on whether these were self-reported or measured in any other way are unavailable. Data were assessed for extraction errors and for plausibility using standardized algorithms, and survey quality by evaluating evidence for selection bias, sample representativeness, response rate, and validity of the diet assessment method Supplementary Methods S1. Measurement comparability across surveys was maximized by using a standardized data analysis approach including averaging all days of dietary assessment to quantify mean individual-level intakes; using harmonized dietary factor definitions and units of measure across surveys; and adjusting for total energy through the residual method and using age-specific energy intakes to reduce measurement error and account for regional differences in body size, metabolic efficiency, and physical activity. The adult male equivalent AME method was used for 15 household-level surveys 3. All included surveys used this definition. Our model estimates intakes for years for which we have survey data available. To incorporate and address differences in data comparability and sampling uncertainty, a Bayesian model with a nested hierarchical structure with random effects by country, region, and globally estimated the mean consumption level of SSBs and its statistical uncertainty for each of population strata across countries for , , , , , , and Primary inputs were the survey-level quantitative data on SSB intakes by country, time, age, sex, education level, and urban or rural residence ; survey characteristics dietary assessment method, type of dietary metric ; and country-year-specific covariates Supplementary Methods 2. Uncertainty of each stratum-specific estimate was quantified using iterations to determine posterior distributions of mean intake jointly by country, year, and sociodemographic subgroup. A second Bayesian model was used to strengthen time trend estimates for dietary factors with corresponding food or nutrient availability data from FAO Food Balance Sheets 54 or the Global Expanded Nutrient Supply The model incorporated country-level intercepts and slopes from these covariates, along with their correlation estimated across countries. No time component was formally included in the model; rather, time was captured by the underlying time variation in the model covariates. This model is commonly referred to as a varying slopes model structure and leverages two-dimensional partial pooling between intercepts and slopes to regularize all parameters and minimize overfitting risk 56 , The final presented results are a combination of these two Bayesian models, as detailed in Supplementary Methods 3. Global, regional, national, and within-country population subgroup intakes of SSBs and their uncertainty were calculated as population-weighted averages using all posterior estimates for each of the demographic strata in each country year. Population weights for each year were derived from the United Nations Population Division 58 , supplemented with data for education and urban or rural status from Barro and Lee 59 and the United Nations Absolute changes and percentage changes in consumption between , , and were calculated at the stratum-specific level using all posterior estimates to account for the full spectrum of uncertainty and standardized to the proportion of individuals within each stratum in to account for changes in demographics over time. Stratum-specific estimates were summed to calculate the differences in intake in males vs. We also assessed the correlation between country-level SSB intakes and the corresponding national sociodemographic development index SDI , and how these relationships changed over time between , , and Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article. GDD data were utilized in agreement with the database guidelines. The derived source data are provided with this paper. The simulations files can be made available to researchers upon request. Eligibility criteria for such requests include utilization for nonprofit purposes only, for appropriate scientific use based on a robust research plan, and by investigators from an academic institution. Note that this agreement does not apply when protected health information or personally identifiable information are shared , 3 email items 1 and 2 to info globaldietarydatabase. Once all documents have been received, the GDD team will be in contact with you within 2—4 weeks regarding subsequent steps. Data will be shared as. Source data are provided with this paper. Custom code was developed using R Version 4. The statistical code can be made available to researchers upon request. GDD will nominate co-authors to be included in any papers generated using GDD-generated statistical code. Klemm, S. Ethics: health equity and dietetics-related inequalities. PubMed Google Scholar. Murray, C. Global burden of 87 risk factors in countries and territories, — a systematic analysis for the Global Burden of Disease Study Lancet , — Google Scholar. Coronavirus disease hospitalizations attributable to cardiometabolic conditions in the United States: a comparative risk assessment analysis. Heart Assoc. Singh, G. Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in Circulation , — Malik, V. 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Intake of sugar sweetened soft drinks among adolescents: trends and social inequality in Denmark Health 26 , 3—8 Figueiredo, N. Trends in sweetened beverages consumption among adults in the Brazilian capitals, Public Health Nutr. Hwang, S. Trends in beverage consumption and related demographic factors and obesity among korean children and adolescents. Nutrients 12 , Gulati, S. Sugar intake, obesity, and diabetes in India. Nutrients 6 , — Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: a systematic assessment of beverage intake in countries. PLoS One 10 , e Department of health and human services. Guideline: sugars intake for adults and children. Geneva, Switzerland, Popkin, B. The nutrition transition to a stage of high obesity and noncommunicable disease prevalence dominated by ultra-processed foods is not inevitable. World Health Organization. WHO Manual on sugar-sweetened beverage taxation policies to promote healthy diets. 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Responses to the Chilean law of food labeling and advertising: exploring knowledge, perceptions and behaviors of mothers of young children. Taillie, L. PLOS Med. Walton, J. Soft drink intake in Europe: a review of data from nationally representative food consumption surveys. Nutrients 15 , Imamura, F. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ , h Miller, V. Evaluation of the quality of evidence of the association of foods and nutrients with cardiovascular disease and diabetes: a systematic review. JAMA Netw. Open 5 , e—e Beal, T. Differences in modelled estimates of global dietary intake. Del Gobbo, L. Assessing global dietary habits: a comparison of national estimates from the FAO and the global dietary database. Willett, W. Nutritional Epidemiology. Oxford Scholarship Online, Vanderlee, L. 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The Bayesian new statistics: hypothesis testing, estimation, meta-analysis, and power analysis from a Bayesian perspective. Download references. This material is based upon work supported by the National Science Foundation under grant number The computational resource is under active development by Research Technology, Tufts Technology Services. The funding agencies had no role in the design of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit for publication. Fundacion Cardiovascular de Colombia, Bucaramanga, Colombia. Institut de Recherche pour le Developpement, Montepellier, France. Julie M. Long, K. University of Manchester, Manchester, United Kingdom. You can also search for this author in PubMed Google Scholar. Conceptualization, L. The investigators did not receive funding from a pharmaceutical company or other agency to write this report. National Institutes of Health, Danone, and Nestle. National Institutes of Health, the U. Department of Agriculture, the Rockefeller Foundation, the U. A peer review file is available. Reprints and permissions. Lara-Castor, L. Sugar-sweetened beverage intakes among adults between and in countries. Nat Commun 14 , Download citation. Received : 29 January Accepted : 29 August Published : 03 October Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative. Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily. Skip to main content Thank you for visiting nature. Download PDF. Subjects Developing world Epidemiology Risk factors Scientific community. Abstract Sugar-sweetened beverages SSBs are associated with cardiometabolic diseases and social inequities. The role of sugar-sweetened beverages in the global epidemics of obesity and chronic diseases Article 21 January Mortality attributable to sugar sweetened beverages consumption in Mexico: an update Article 10 December Costs of obesity attributable to the consumption of sugar-sweetened beverages in Brazil Article Open access 17 June Introduction What people eat and drink is one of the most important determinants of health as well as health equity 1. Full size image. Discussion This analysis, based on new GDD estimates which incorporate data on mostly national, individual-level dietary surveys, provides estimates of SSB intakes and trends between and globally, regionally, and nationally. Methods Ethics and inclusion statement Data informing the GDD modeling estimates for this study, including from LMICs, were collected between and in the form of dietary intake surveys. Data sources The approach and results of our survey search strategy by dietary factor, time, and region have been detailed elsewhere Data extraction For each survey, we extracted data using standardized methods on survey characteristics and dietary metrics, units, mean, and standard deviation of intake, by age, sex, education level, and urban or rural residence 52 , Data modeling Our model estimates intakes for years for which we have survey data available. Statistical analysis Global, regional, national, and within-country population subgroup intakes of SSBs and their uncertainty were calculated as population-weighted averages using all posterior estimates for each of the demographic strata in each country year. Reporting summary Further information on research design is available in the Nature Portfolio Reporting Summary linked to this article. Code availability Custom code was developed using R Version 4. References Klemm, S. Google Scholar Pedroza-Tobias, A. Google Scholar Caro, J. PubMed Google Scholar Download references. Geleijnse Washington University in St. Louis, St. View author publications. Long , K. Michael Hambidge , Nancy F. Krebs , Aminul Haque , Gudrun B. Ethics declarations Competing interests The investigators did not receive funding from a pharmaceutical company or other agency to write this report. Supplementary information. Supplementary Information. Peer Review File. Description of Additional Supplementary Files. Supplementary Data 1. Supplementary Data 2. Supplementary Data 3. Reporting Summary. Source data Source Data. About this article. Cite this article Lara-Castor, L. Copy to clipboard. This article is cited by Kids SIPsmartER reduces sugar-sweetened beverages among Appalachian middle-school students and their caregivers: a cluster randomized controlled trial Jamie M. Do Quynh H. Nguyen Lan T. Mori Nature Metabolism Search Search articles by subject, keyword or author. Show results from All journals This journal. 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