Important Food Sources of Fructose-Containing Sugars and Incident Hypertension: A Systematic Review and Dose-Response Meta-Analysis of Prospective Cohort Studies

Liu Q, Ayoub-Charette S, Khan TA, et al.

J Am Heart Assoc 2019; 8:e010977. DOI: 10.1161/JAHA.118.010977.


  • To assess the relation of important food sources of fructose-containing sugars with incident hypertension.


  • Hypertension is a major risk factor for developing cardiovascular disease, and the global prevalence of hypertension has been increasing in the past decades.
  • Fructose and fructose-containing sugars have been implicated as a dietary contributor to the development of hypertension.
  • Sugar-sweetened beverages (SSBs) are a major source of fructose in the North American diet. However, although systematic reviews and meta-analyses of prospective cohort studies have shown an association between SSBs and incident hypertension, the same has not been shown for the fructose-containing sugars they contain independent of food form, both in prospective cohort studies and in controlled feeding trials.
  • It is also unclear whether the association observed for SSBs holds for other important food sources of fructose-containing sugars, such as fruit and fruit-based products, grains and grain-based products, dairy and dairy-based products, and sweets and desserts.
  • To address this gap, the authors conducted a systematic review and meta-analysis of prospective cohort studies of the relation of important food sources of fructose-containing sugars and incident hypertension.


  • The Cochrane Handbook for Systematic Reviews of Interventions was followed to conduct this systematic review and meta-analysis. Results were reported according to the MOOSE (Meta-Analysis of Observational Studies in Epidemiology) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
  • The authors conducted systematic searches in MEDLINE, EMBASE, and Cochrane Library databases through December 13, 2018 with no language restriction. Targeted manual searches served to supplement database searches, and the search terms used reflected the most consumed food sources of fructose-containing sugars in the North American diet, as well as the study design and outcome of interest.


  • The authors identified 26 reports, including 15 prospective cohorts.
  • Sugar-sweetened beverages showed an association with incident hypertension, whereas fruit and yogurt showed protective associations throughout the dose range.
  • One hundred percent fruit juice showed a protective association only at moderate doses. The pair-wise protective association of dairy desserts was not supported by linear dose-response analysis. Fruit drinks, dairy desserts and sweet snacks were not associated with hypertension.
  • It important to note, however, that the certainty of the evidence was “low” for sugar-sweetened beverages, 100% fruit juice, fruit, and yogurt and “very low” for fruit drinks, sweet snacks, and dairy desserts.


  • The authors concluded that the so-called harmful association between sugar-sweetened beverages and hypertension does not extend to other important food sources of fructose-containing sugars.
  • Further research is needed to improve our estimates and better understand the dose-response relationship between food sources of fructose-containing sugars and hypertension.

Points to Consider

  • As noted in the publication, the overall quality and strength of the evidence included in this review ranged from “low” to “very low”. Weaknesses of the studies included inconsistency, indirectness, imprecision and publication bias.
  • A limited number of cohort comparisons was also noted for several food sources of sugars, which resulted in unbalanced representation in the review.