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JAMA Intern Med. 2019 Sep 3. doi: 10.1001/jamainternmed.2019.2478. [Epub ahead of print]

Association Between Soft Drink Consumption and Mortality in 10 European Countries.

Author information

School of Public Health, Physiotherapy and Sports Science, University College Dublin, Dublin, Ireland.
School of Agriculture and Food Science, University College Dublin, Dublin, Ireland.
Section of Nutrition and Metabolism, International Agency for Research on Cancer, Lyon, France.
Instituto de Investigación Sanitaria Illes Balears (IdISBa), University Hospital of Son Espases, Palma de Mallorca, Spain.
CIBER Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Madrid, Spain.
School of Public Health, MRC-PHE Centre for Environment and Health, Imperial College London, London, United Kingdom.
Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom.
CESP, Faculté de Médecine, Université Paris-Sud, Faculté de Médecine, UVSQ, INSERM, Université Paris-Saclay, Villejuif, France.
Gustave Roussy, F-94805, Villejuif, France.
German Cancer Research Center (DKFZ), Division of Cancer Epidemiology, Heidelberg, Germany.
Department of Epidemiology, German Institute of Human Nutrition, Potsdam-Rehbrücke, Germany.
Nutrition, Immunity and Metabolism Start-up Lab, Department of Epidemiology, Potsdam-Rehbrücke, Germany.
Danish Cancer Society Research Center, Copenhagen, Denmark.
Department of Public Health, Aarhus University, Aarhus, Denmark.
Office of the Director, International Agency for Research on Cancer, Lyon, France.
Department of Community Medicine, University of Tromsø, The Arctic University of Norway, Tromsø, Norway.
Department of Nursing and Health Promotion, Oslo Metropolitan University, Oslo, Norway.
Public Health Directorate, Asturias, Spain.
Unit of Nutrition and Cancer, Cancer Epidemiology Research Program, Catalan Institute of Oncology-IDIBELL, L'Hospitalet de Llobregat, Barcelona, Spain.
Escuela Andaluza de Salud Pública, Instituto de Investigación Biosanitaria Granada, Granada, Spain.
CIBER de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain.
Public Health Division of Gipuzkoa, BioDonostia Research Institute, San Sebastian, Spain.
Department of Epidemiology, Murcia Regional Health Council, IMIB-Arrixaca, Murcia, Spain.
Navarra Public Health Institute, Pamplona, Spain.
IdiSNA, Navarra Institute for Health Research, Pamplona, Spain.
University of Cambridge School of Clinical Medicine, Clinical Gerontology Unit, Addenbrooke's Hospital, Cambridge, United Kingdom.
Cancer Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom.
Hellenic Health Foundation, Athens, Greece.
WHO Collaborating Center for Nutrition and Health, Unit of Nutritional Epidemiology and Nutrition in Public Health, Department of Hygiene, Epidemiology and Medical Statistics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
Pulmonary Medicine Department, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Haidari, Greece.
Cancer Risk Factors and Life-Style Epidemiology Unit, Institute for Cancer Research, Prevention and Clinical Network-ISPRO, Florence, Italy.
Epidemiology and Prevention Unit, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy.
Cancer Registry and Histopathology Department, Civic-M. P. Arezzo Hospital, ASP Ragusa, Ragusa, Italy.
Unit of Cancer Epidemiology, Città della Salute e della Scienza University-Hospital and Center for Cancer Prevention (CPO), Turin, Italy.
Dipartimento di Medicina Clinica e Sperimentale, Federico II University, Naples, Italy.
Department for Determinants of Chronic Diseases (DCD), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
Department of Gastroenterology and Hepatology, University Medical Centre, Utrecht, the Netherlands.
Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Pantai Valley, Kuala Lumpur, Malaysia.
Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.
Environmental Epidemiology, Institute for Risk Assessment Sciences (IRAS), Utrecht University, Utrecht, the Netherlands.
Nutritional Epidemiology, Department of Clinical Sciences Malmö, Lund University, Malmö, Sweden.
Department of Radiation Sciences, Oncology, Umeå University, Umeå, Sweden.
Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece.



Soft drinks are frequently consumed, but whether this consumption is associated with mortality risk is unknown and has been understudied in European populations to date.


To examine the association between total, sugar-sweetened, and artificially sweetened soft drink consumption and subsequent total and cause-specific mortality.

Design, Setting, and Participants:

This population-based cohort study involved participants (n = 451 743 of the full cohort) in the European Prospective Investigation into Cancer and Nutrition (EPIC), an ongoing, large multinational cohort of people from 10 European countries (Denmark, France, Germany, Greece, Italy, the Netherlands, Norway, Spain, Sweden, and the United Kingdom), with participants recruited between January 1, 1992, and December 31, 2000. Excluded participants were those who reported cancer, heart disease, stroke, or diabetes at baseline; those with implausible dietary intake data; and those with missing soft drink consumption or follow-up information. Data analyses were performed from February 1, 2018, to October 1, 2018.


Consumption of total, sugar-sweetened, and artificially sweetened soft drinks.

Main Outcomes and Measures:

Total mortality and cause-specific mortality. Hazard ratios (HRs) and 95% CIs were estimated using multivariable Cox proportional hazards regression models adjusted for other mortality risk factors.


In total, 521 330 individuals were enrolled. Of this total, 451 743 (86.7%) were included in the study, with a mean (SD) age of 50.8 (9.8) years and with 321 081 women (71.1%). During a mean (range) follow-up of 16.4 (11.1 in Greece to 19.2 in France) years, 41 693 deaths occurred. Higher all-cause mortality was found among participants who consumed 2 or more glasses per day (vs consumers of <1 glass per month) of total soft drinks (hazard ratio [HR], 1.17; 95% CI, 1.11-1.22; P < .001), sugar-sweetened soft drinks (HR, 1.08; 95% CI, 1.01-1.16; P = .004), and artificially sweetened soft drinks (HR, 1.26; 95% CI, 1.16-1.35; P < .001). Positive associations were also observed between artificially sweetened soft drinks and deaths from circulatory diseases (≥2 glasses per day vs <1 glass per month; HR, 1.52; 95% CI, 1.30-1.78; P < .001) and between sugar-sweetened soft drinks and deaths from digestive diseases (≥1 glass per day vs <1 glass per month; HR, 1.59; 95% CI, 1.24-2.05; P < .001).

Conclusions and Relevance:

This study found that consumption of total, sugar-sweetened, and artificially sweetened soft drinks was positively associated with all-cause deaths in this large European cohort; the results are supportive of public health campaigns aimed at limiting the consumption of soft drinks.

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