Fructose-containing food sources and blood pressure: A systematic review and meta-analysis of controlled feeding trials

Qi Liu; Laura Chiavaroli; Sabrina Ayoub-Charette; Amna Ahmed; Tauseef A Khan; Fei Au-Yeung; Danielle Lee; Annette Cheung; Andreea Zurbau; Vivian L Choo; Sonia Blanco Mejia; Russell J de Souza; Thomas M S Wolever; Lawrence A Leiter; Cyril W C Kendall; David J A Jenkins; John L Sievenpiper

doi:10.1371/journal.pone.0264802

Fructose-containing food sources and blood pressure: A systematic review and meta-analysis of controlled feeding trials

PLoS One. 2023 Aug 15;18(8):e0264802. doi: 10.1371/journal.pone.0264802. eCollection 2023.

Authors

Qi Liu^{1

2}, Laura Chiavaroli^{1

2}, Sabrina Ayoub-Charette^{1

2}, Amna Ahmed^{1

2}, Tauseef A Khan^{1

2}, Fei Au-Yeung^{1

2

3}, Danielle Lee^{1

2}, Annette Cheung^{1

2}, Andreea Zurbau^{1

2

3}, Vivian L Choo^{1

2

4}, Sonia Blanco Mejia^{1

2}, Russell J de Souza^{1

2

5

6}, Thomas M S Wolever^{1

3}, Lawrence A Leiter^{1

2

7

8

9}, Cyril W C Kendall^{1

2

10}, David J A Jenkins^{1

2

7

8

9}, John L Sievenpiper^{1

2

7

8

9}

Affiliations

¹ Department of Nutritional Sciences, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
² Toronto 3D Knowledge Synthesis and Clinical Trials Unit, Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ontario, Canada.
³ INQUIS Clinical Research Ltd. (formerly GI Labs), Toronto, Ontario, Canada.
⁴ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
⁵ Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada.
⁶ Population Health Research Institute, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada.
⁷ Division of Endocrinology and Metabolism, Department of Medicine, St. Michael's Hospital, Toronto, Ontario, Canada.
⁸ Department of Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
⁹ Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.
¹⁰ College of Pharmacy and Nutrition, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Abstract

Whether food source or energy mediates the effect of fructose-containing sugars on blood pressure (BP) is unclear. We conducted a systematic review and meta-analysis of the effect of different food sources of fructose-containing sugars at different levels of energy control on BP. We searched MEDLINE, Embase and the Cochrane Library through June 2021 for controlled trials ≥7-days. We prespecified 4 trial designs: substitution (energy matched substitution of sugars); addition (excess energy from sugars added); subtraction (excess energy from sugars subtracted); and ad libitum (energy from sugars freely replaced). Outcomes were systolic and diastolic BP. Independent reviewers extracted data. GRADE assessed the certainty of evidence. We included 93 reports (147 trial comparisons, N = 5,213) assessing 12 different food sources across 4 energy control levels in adults with and without hypertension or at risk for hypertension. Total fructose-containing sugars had no effect in substitution, subtraction, or ad libitum trials but decreased systolic and diastolic BP in addition trials (P<0.05). There was evidence of interaction/influence by food source: fruit and 100% fruit juice decreased and mixed sources (with sugar-sweetened beverages [SSBs]) increased BP in addition trials and the removal of SSBs (linear dose response gradient) and mixed sources (with SSBs) decreased BP in subtraction trials. The certainty of evidence was generally moderate. Food source and energy control appear to mediate the effect of fructose-containing sugars on BP. The evidence provides a good indication that fruit and 100% fruit juice at low doses (up to or less than the public health threshold of ~10% E) lead to small, but important reductions in BP, while the addition of excess energy of mixed sources (with SSBs) at high doses (up to 23%) leads to moderate increases and their removal or the removal of SSBs alone (up to ~20% E) leads to small, but important decreases in BP in adults with and without hypertension or at risk for hypertension. Trial registration: Clinicaltrials.gov: NCT02716870.

Copyright: © 2023 Liu et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Publication types

Meta-Analysis
Systematic Review
Research Support, Non-U.S. Gov't

MeSH terms

Adult
Blood Pressure
Fructose*
Fruit
Humans
Hypertension*
Sugars

Substances

Fructose
Sugars

Associated data

ClinicalTrials.gov/NCT02716870

Grants and funding

This work was supported by Diabetes Canada (CS-5-15-4771-JS) and the Canadian Institutes of Health Research (funding reference number, 129920). The Diet, Digestive tract, and Disease (3-D) Centre, funded through the Canada Foundation for Innovation (CFI) and the Ministry of Research, and Innovation’s Ontario Research Fund (ORF), provided the infrastructure for the conduct of this project. LC was funded by a Mitacs-Elevate Postdoctoral Fellowship Award. SA-C was funded by a CIHR Canadian Graduate Scholarships Master’s Award, the Loblaw Food as Medicine Graduate Award, the Ontario Graduate Scholarship (OGS), and the CIHR Canadian Graduate Scholarship Doctoral Award (funding reference number 476251).TAK was funded by a Toronto 3D Foundation Postdoctoral Fellowship Award. DL was funded by a St. Michael’s Hospital Research Training Centre Scholarship. AZ was funded by a BBDC Postdoctoral Fellowship. AC and AA were funded by Toronto 3D Foundation MSc Scholarship Awards. DJAJ was funded by the Government of Canada through the Canada Research Chair Endowment. JLS was funded by a PSI Graham Farquharson Knowledge Translation Fellowship, Diabetes Canada Clinician Scientist award, CIHR INMD/CNS New Investigator Partnership Prize, and Banting & Best Diabetes Centre Sun Life Financial New Investigator Award. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.