Prenatal and Early Life Fructose, Fructose-Containing Beverages, and Midchildhood Asthma

Annals Amer Thoracic Society (2018) 15 (2); LS, Rifas-Shiman SL, Oken E, Litonjua AA and Gold DR. — Download PDF


  • To examine associations of maternal prenatal and early childhood intake of sugar-sweetened beverages and fructose with current asthma in midchildhood, median age, 7.7 years.


  • Concurrent with the rise in asthma has been increased caloric intake from added sugars, most notably in sugar-sweetened beverages, which has been linked to the obesity epidemic.
  • Many studies have demonstrated links between obesity/overweight and asthma, though the biological mechanisms of these associations and their implications for asthma therapy are still not fully understood.
  • Recent studies suggest that in addition to influencing asthma through increasing the risk of obesity, high fructose intake may influence the risk of lung disease at least in part through distinct mechanisms. In addition to their adiposity-related inflammatory potential, beverages containing excess free fructose may have specific effects on the gut that may have downstream influences on the lung.


  •  Between 1999 and 2002, women in early pregnancy were recruited into Project Viva from eight obstetric offices of Atrius Harvard Vanguard Medical Associates, a multi-specialty group practice in eastern Massachusetts.  The final sample size for analysis was 1,068 mother–child pairs.
  • In-person study visits with participating mothers were performed at the end of the first and second trimesters of pregnancy and with mothers and children during the first few days after delivery. In-person visits were conducted with mothers and children in early and mid-childhood.
  • Data on consumption of beverages during pregnancy were contained from semi-quantitative food frequency questionnaires (FFQs) completed by expectant mothers after the first and second research visits, at mean gestational ages 11.9 and 29.2 weeks. The FFQ included three questions on regular (sugary) soda intake, three questions on sugar-free soda, five questions on fruit juice, and one question on fruit drinks. Sugar-sweetened beverages were defined as regular soda and fruit drinks.
  • The children’s dietary intakes were assessed using an 88-item semi-quantitative child FFQ which was completed by the mothers when their children were in early childhood (median age 3.3 years).  The FFQ included one question on regular (sugary) soda intake, one question on sugar-free soda, two questions on fruit juice (orange juice and other 100% juice), one question on fruit drinks, and one question on hot chocolate.
  • Fructose intake was calculated by multiplying the frequency response of each item (foods and beverages) on the FFQ by the fructose content based on average serving size.
  • On the midchildhood questionnaire, asthma questions from the International Study of Asthma and Allergies in Childhood were utilized. The main outcome of “current asthma” was defined as defined as the mother’s affirmative response to her child’s ever having a doctor’s diagnosis of asthma, plus either report of wheezing or asthma medication use in the past 12 months.


  • Correlates of higher pregnancy sugar-sweetened beverage intake included younger maternal age, higher pre-pregnancy BMI, and smoking during pregnancy as well as indicators of disadvantage/lower socioeconomic status (i.e., lower education and household income). Higher pregnancy sugar-sweetened beverage intake was also correlated with child current asthma. Associations were similar for fructose intake.
  • The largest source of fructose-rich beverage intake was citrus juice for mothers, and non-citrus juice for children.  Mothers reported more sugar-sweetened beverage intake in the form of soda and punch than children.
  • Higher pregnancy intake of sugar-sweetened beverages and total fructose were associated with greater odds of mid-childhood current asthma, as was higher early childhood intake of total fructose.


  • Higher intake of sugar-sweetened beverages and fructose may influence asthma, either through increasing adiposity, as well as adiposity-related pulmonary restriction and inflammation, or through adiposity-independent mechanisms.
  • Maternal prenatal sugar-sweetened beverage intake and early childhood total fructose intake were associated with asthma in mid-childhood.
  • These findings contribute to the literature that should be considered when developing recommendations regarding consumption and availability of these drinks during pregnancy and early childhood.
  • Further evaluation of potential mechanisms for influences of total fructose associated with asthma development is warranted, including further assessment of effects of fructose and fructose metabolites on airway inflammation or hyper-reactivity that may be independent of obesity.

Points to Consider:

  • The individuals in this cohort were relatively socioeconomically advantaged. As a result, these findings may not be generalizable to more disadvantaged populations.
  • Sugar-sweetened beverage intake was self-reported. There may have been inaccuracies due to recall, social desirability and other biases.