Cohort studycited by the Tayebat archivefull text checked★ key study A-SOD-17 in-depth review

Soft drinks and death in 10 European countries

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

Overview

Mullee A et al.. JAMA Intern Med 2019 · PMID 31479109 · DOI 10.1001/jamainternmed.2019.2478

Two or more soft drinks a day were linked with higher death rates; for diet drinks the link was even stronger, which may partly reflect who chooses diet drinks.

Does the study support the specific claim? Partly · Methodological quality: high

Original publication

Plain-language summary

Study explained simply

What did the researchers want to find out?: Are total, SSB and ASB soft drinks associated with total and cause-specific mortality?
How was the study done?: Population-based prospective cohort (EPIC), 10 European countries.
How many people, animals or samples were studied?: 451,743; 41,693 deaths; Adults without cancer, heart disease, stroke or diabetes
What was actually found?: >=2 glasses/day vs <1/month: total soft drinks HR 1.17 (1.11-1.22); SSB 1.08 (1.01-1.16); ASB 1.26 (1.16-1.35); ASB and circulatory deaths 1.52 (1.30-1.78); SSB >=1/day and digestive deaths 1.59 (1.24-2.05).
How large was the observed effect?: HR 1.17 total; 1.08 SSB; 1.26 ASB
What do the results mean in everyday life?: Soft drinks are linked with earlier death in Europe.
What are the study's limitations?: Observational; drink intake asked only once at baseline; residual confounding; diet-drink results may reflect people at risk switching to diet drinks; sugar-sweetened drinks were not linked to heart or circulatory deaths in this cohort.
What does it say about Elawady's specific claim?: Supports C-SOD-03 and C-SOD-10.
Do the results apply to Germany and Europe?: High (includes Germany).
What can explicitly not be concluded from this study?: It cannot prove that soft drinks cause death, nor that sugary soft drinks raise cardiovascular death in Europeans (that association was not significant here).

Scientific in-depth review

1. Full reference

Authors: Mullee A, Romaguera D, Pearson-Stuttard J, Viallon V, Stepien M, Freisling H, Fagherazzi G, Mancini FR, Boutron-Ruault MC, Kühn T, Kaaks R, Boeing H, Aleksandrova K, Tjønneland A, Halkjær J, Overvad K, Weiderpass E, Skeie G, Parr CL, Quirós JR, Agudo A, Sánchez MJ, Amiano P, Cirera L, Ardanaz E, Khaw KT, Tong TYN, Schmidt JA, Trichopoulou A, Martimianaki G, Karakatsani A, Palli D, Agnoli C, Tumino R, Sacerdote C, Panico S, Bueno-de-Mesquita B, Verschuren WMM, Boer JMA, Vermeulen R, Ramne S, Sonestedt E, van Guelpen B, Holgersson PL, Tsilidis KK, Heath AK, Muller D, Riboli E, Gunter MJ, Murphy N
Journal: JAMA Intern Med
Year: 2019
Identifier: PMID 31479109 DOI 10.1001/jamainternmed.2019.2478 · PMC6724165
Verification: verified – PubMed E-utilities efetch, 2026-10-25
Retracted: no
Corrections: PubMed lists: ErratumIn (JAMA Intern Med. 2019 Nov 1;179(11):1607. doi: 10.1001/jamainternmed.2019.5327.)
Extent checked: full text
Conflicts of interest and funding: COI statement present: grants to individual authors from University College Dublin, IARC, MRC, Cancer Research UK and the EU; no industry relationships reported. Funded by the European Commission (DG-SANCO), IARC and national public/charitable bodies (incl. German Cancer Aid, DKFZ, BMBF); funders had no role in design, analysis or publication.

2. Research question

Are total, SSB and ASB soft drinks associated with total and cause-specific mortality?

3. Study design and population

Study design: Cohort study – Population-based prospective cohort (EPIC), 10 European countries.
Population: EPIC participants from the general populations of 10 European countries; mean age 50.8 years; 71.1% women; free of cancer, heart disease, stroke and diabetes at baseline
Country: Denmark, France, Germany, Greece, Italy, Netherlands, Norway, Spain, Sweden, UK
Period: Recruitment 1992-2000; end of follow-up 2008-2013 depending on centre; mean follow-up 16.4 years (11.1 Greece to 19.2 France)
Sample size: 451,743 of 521,330 enrolled (86.7%); 41,693 deaths (18,003 cancer, 9,106 circulatory, 1,213 digestive)
Inclusion and exclusion criteria: Excluded baseline cancer (n=22,537), heart disease (12,619), stroke (3,683), diabetes (12,461), top/bottom 1% energy intake/requirement ratio (8,828), missing soft-drink or follow-up data (9,459).

4. Methods and endpoints

Exposure / intervention: Baseline self-reported soft-drink consumption (country-specific validated questionnaires; 1 glass ~250 mL); total, sugar-sweetened and artificially sweetened (type not recorded in Italy, Spain and Sweden)
Comparator: <1 glass/month
Endpoints: All-cause and cause-specific mortality
Statistical methods: Cox models with age as time scale, stratified by age, sex and centre; adjusted for BMI, physical activity, education, alcohol, smoking status/intensity/duration, contraceptive pill, menopausal status and hormone therapy, energy, red/processed meat, fruit and vegetables, coffee and juice; SSB and ASB mutually adjusted. Restricted cubic splines; country random-effects meta-analysis; sensitivity analyses (no BMI adjustment, excluding first 8 years, non-consumers as reference, WCRF score, sole consumers, ascertainment method) and negative control (external causes).

5. Actual results

Results: >=2 glasses/day vs <1 glass/month, all-cause mortality: total soft drinks HR 1.17 (1.11-1.22); SSB 1.08 (1.01-1.16) (men 1.09 [0.99-1.20], women 1.06 [0.95-1.18]); ASB 1.26 (1.16-1.35). Circulatory deaths: total 1.27 (1.14-1.40); ASB 1.52 (1.30-1.78); SSB 1.11 (0.95-1.30), not significant. Ischaemic heart disease deaths (>=1 glass/day): total 1.19 (1.06-1.33); ASB 1.41 (1.11-1.79); SSB 1.04 (0.87-1.23). Digestive deaths (>=1 glass/day): SSB 1.59 (1.24-2.05); ASB 0.99 (0.65-1.50). Overall cancer deaths: no association (total 1.02 [0.95-1.11]); colorectal cancer deaths total 1.25 (1.07-1.47); Parkinson disease deaths total 1.59 (1.07-2.36). J-shaped dose-response with higher risk above ~125 mL/day ASB and ~225 mL/day SSB. Heterogeneity across countries for SSB (I2=63%), none for ASB (I2=0%). Associations persisted after excluding the first 8 years and without BMI adjustment; null for external-cause deaths (negative control).
Absolute risks: Absolute rates not reported in full text; crude death counts only (e.g. total soft drinks >=2 glasses/day: 1,869 deaths among 16,200 participants; <1 glass/month: 21,032 among 225,543; not age-standardised).
Authors' conclusion: Total, sugar-sweetened and artificially sweetened soft drinks were positively associated with all-cause deaths; ASB with circulatory deaths and SSB with digestive deaths; further study of artificial sweeteners needed; results support public-health campaigns to reduce soft-drink consumption. Authors state causality cannot be established.

6. Strengths

Very large multinational European cohort with ~42,000 deaths
Long follow-up; low loss to follow-up (1.5%)
Extensive sensitivity analyses incl. 8-year lag and negative-control outcome
Public funding; funders had no role

7. Weaknesses

Single baseline assessment of soft-drink intake (authors)
Residual confounding acknowledged by authors
Reverse causation plausible for ASB (people at risk switching to diet drinks), partly addressed by 8-year exclusion
Soft-drink type not recorded in Italy, Spain and Sweden
Questionnaire wording and glass size differ between centres; validity correlations 0.46-0.77
Many cause-specific outcomes tested (multiple comparisons; e.g. Parkinson finding)
SSB association with all-cause mortality small and heterogeneous across countries

8. Risk of bias

Orienting tool: ROBINS-E
Type of assessment: structured assessment based on the full text by a single reviewer (no formal double review)
Full formal assessment: no
Overall risk of bias: some concerns
Rationale: Structured single-reviewer judgement from the full text; a complete formal ROBINS-E assessment requires two independent reviewers and a protocol.

8. Risk of bias
Domain	Judgement	Rationale
Confounding	some concerns	Broad adjustment for smoking, BMI, activity, education and diet; high consumers differed in smoking and education; residual confounding acknowledged.
Exposure measurement	some concerns	Single baseline questionnaire, heterogeneous instruments; moderate validity (r 0.46-0.77); type missing in 3 countries.
Selection of participants	low	Population-based recruitment; prevalent major disease excluded; 86.7% of cohort analysed.
Post-exposure interventions	some concerns	Drink habits and diet changes over 16 years (including switching to diet drinks) not captured.
Missing data	low	Loss to follow-up 1.5%; 9,459 excluded for missing exposure or follow-up.
Outcome measurement	low	Registry linkage or active follow-up; ICD-10 causes; SSB association stronger with active follow-up, a minor concern.
Selection of reported result	some concerns	Many cause-specific outcomes without multiplicity correction; no pre-registered protocol; null results (cancer, SSB circulatory) also reported.

Full-text review (25 October 2026): Headline numbers confirmed. Added from tables: SSB not associated with circulatory (HR 1.11, 0.95-1.30) or ischaemic heart disease deaths (1.04, 0.87-1.23); sex-specific SSB estimates non-significant; no cancer association; J-shaped curves; heterogeneity for SSB; 8-year-lag and negative-control results. COI statement exists (abstract-based entry said empty) and funding detailed. Domain-level ROBINS-E (overall some_concerns, unchanged).

9. Assessment of the statistical interpretation

Precise estimates owing to size. The SSB-all-cause HR of 1.08 is small and borderline in each sex separately; SSB was NOT associated with circulatory or ischaemic heart disease deaths. The ASB association (HR 1.26; circulatory 1.52) is larger, persisted after excluding the first 8 years and in normal-weight participants, but reverse causation and residual confounding remain plausible.

10. Relevance to the specific claim

Supports C-SOD-03 and C-SOD-10.

11. Independent contrary findings

A-SOD-14, A-SOD-15 (ASB null for CHD).

12. Transferability to Germany and Europe

High (includes Germany).

13. Overall methodological judgement

Strong European data showing associations of high soft-drink intake with all-cause mortality. For sugar-sweetened drinks specifically, the signal is small and limited to all-cause and digestive mortality; it does not support an SSB-cardiovascular mortality link. The ASB-circulatory association is open to reverse causation.

Multidimensional assessment
Multidimensional assessment
Authenticity of the source	verified
Methodological quality	high
Risk of bias	some concerns
Precision of results	high
Directness	direct
Reproducibility	partly replicated
Consistency with the overall evidence	mixed
Regional transferability	high
Adequacy of the interpretation (by the archive)	essentially correct but incomplete

14. Open questions

Causality of ASB association.

15. Linked fact checks

Sugar-sweetened soft drinks raise the risk of coronary heart disease, cardiovascular death and early death (e.g., two or more daily servings: +35% coronary heart disease in women; +31% cardiovascular and +21% total mortality). – Studies with mixed or unclear results
Diet soda is not a safe alternative to sugary soda: artificially sweetened drinks are linked to higher mortality, especially circulatory deaths. – Studies supporting the claim

Use by the Tayebat archive

Note: according to the archive, the studies were compiled by the archive operators. Whether Dr. Elawady himself cited this study is not established.

What the archive says about the study: Largest European cohort, 451,000 people: two or more daily soft drinks raised all-cause mortality by 17%; diet drinks specifically linked to circulatory mortality (HR 1.52).
A. What was actually studied?: Soft drinks and mortality in EPIC.
B. What did the authors find?: All-cause mortality HR 1.17 (total), 1.08 (SSB), 1.26 (ASB) for >=2 glasses/day; ASB circulatory deaths HR 1.52; SSB digestive deaths HR 1.59; SSB not associated with circulatory or ischaemic heart disease deaths.
C. What conclusions do the authors themselves draw?: Positive associations; supports limiting soft drinks.
D. What does the archive derive from it?: Diet drinks are not a safe alternative.
E. Is this derivation scientifically justified?: Numbers correct (17% refers to total soft drinks). Causal wording ('raised') goes beyond the authors, who state causality cannot be established; the reverse-causation caveat for diet drinks is omitted; the null SSB-circulatory finding is not mentioned.
Adequacy of the interpretation (by the archive): essentially correct but incomplete