Please%20read%20the%20text%20carefully.%20Identify%20the%20main%20topic%20and%20key%20points%20covered%20in%20the%20text.%20%0AWrite%20a%20concise%20summary%20of%20the%20text%20in%20exactly%203%20bullets%20in%20markdown,%20focusing%20solely%20on%20the%20main%20topic%20and%20key%20points%20you%20identified.%20Your%20output%20should%20contain%20only%20the%20summary%20text%20itself.%20Do%20not%20include%20any%20explanations,%20introduction,%20or%20other%20extraneous%20text%20like%20%22%20Here%20is%20a%20concise%20summary...%22.%20The%20summary%20should%20be%20able%20to%20stand%20alone.%20%0AHere%20is%20the%20text%20to%20summarize:%0A%3Ctext%3E%0ASkip%2520to%2520main%2520content%250ATop%2520bar%2520navigation%250A%250AFrontiers%2520in%2520Public%2520Health%250AAbout%2520us%250AAbout%2520us%250A%2509%25E2%2580%25A2%2509Who%2520we%2520are%250A%2509%25E2%2580%25A2%2509Mission%2520and%2520values%250A%2509%25E2%2580%25A2%2509History%250A%2509%25E2%2580%25A2%2509Leadership%250A%2509%25E2%2580%25A2%2509Awards%250A%2509%25E2%2580%25A2%2509Impact%2520and%2520progress%250A%2509%25E2%2580%25A2%2509Frontiers'%2520impact%250A%2509%25E2%2580%25A2%2509Progress%2520Report%25202022%250A%2509%25E2%2580%25A2%2509All%2520progress%2520reports%250A%2509%25E2%2580%25A2%2509Publishing%2520model%250A%2509%25E2%2580%25A2%2509How%2520we%2520publish%250A%2509%25E2%2580%25A2%2509Open%2520access%250A%2509%25E2%2580%25A2%2509Fee%2520policy%250A%2509%25E2%2580%25A2%2509Peer%2520review%250A%2509%25E2%2580%25A2%2509Research%2520integrity%250A%2509%25E2%2580%25A2%2509Research%2520Topics%250A%2509%25E2%2580%25A2%2509Services%250A%2509%25E2%2580%25A2%2509Societies%250A%2509%25E2%2580%25A2%2509National%2520consortia%250A%2509%25E2%2580%25A2%2509Institutional%2520partnerships%250A%2509%25E2%2580%25A2%2509Collaborators%250A%2509%25E2%2580%25A2%2509More%2520from%2520Frontiers%250A%2509%25E2%2580%25A2%2509Frontiers%2520Forum%250A%2509%25E2%2580%25A2%2509Frontiers%2520Planet%2520Prize%250A%2509%25E2%2580%25A2%2509Press%2520office%250A%2509%25E2%2580%25A2%2509Sustainability%250A%2509%25E2%2580%25A2%2509Career%2520opportunities%250A%2509%25E2%2580%25A2%2509Contact%2520us%250AAll%2520journalsAll%2520articles%2520Submit%2520your%2520research%250A%250ASearch%250A%250A%250AFrontiers%2520in%2520Public%2520Health%250ASections%250ASections%250A%2509%25E2%2580%25A2%2509Aging%2520and%2520Public%2520Health%250A%2509%25E2%2580%25A2%2509Children%2520and%2520Health%250A%2509%25E2%2580%25A2%2509Digital%2520Public%2520Health%250A%2509%25E2%2580%25A2%2509Disaster%2520and%2520Emergency%2520Medicine%250A%2509%25E2%2580%25A2%2509Environmental%2520Health%2520and%2520Exposome%250A%2509%25E2%2580%25A2%2509Health%2520Economics%250A%2509%25E2%2580%25A2%2509Infectious%2520Diseases:%2520Epidemiology%2520and%2520Prevention%250A%2509%25E2%2580%25A2%2509Injury%2520Prevention%2520and%2520Control%250A%2509%25E2%2580%25A2%2509Life-Course%2520Epidemiology%2520and%2520Social%2520Inequalities%2520in%2520Health%250A%2509%25E2%2580%25A2%2509Occupational%2520Health%2520and%2520Safety%250A%2509%25E2%2580%25A2%2509Planetary%2520Health%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520Education%2520and%2520Promotion%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520Policy%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520and%2520Nutrition%250A%2509%25E2%2580%25A2%2509Public%2520Mental%2520Health%250A%2509%25E2%2580%25A2%2509Radiation%2520and%2520Health%250A%2509%25E2%2580%25A2%2509Substance%2520Use%2520Disorders%2520and%2520Behavioral%2520Addictions%250AArticlesResearch%2520TopicsEditorial%2520board%250AAbout%2520journal%250AAbout%2520journal%250A%2509%25E2%2580%25A2%2509Scope%250A%2509%25E2%2580%25A2%2509Field%2520chief%2520editors%250A%2509%25E2%2580%25A2%2509Mission%2520%2526%2520scope%250A%2509%25E2%2580%25A2%2509Facts%250A%2509%25E2%2580%25A2%2509Journal%2520sections%250A%2509%25E2%2580%25A2%2509Open%2520access%2520statement%250A%2509%25E2%2580%25A2%2509Copyright%2520statement%250A%2509%25E2%2580%25A2%2509Quality%250A%2509%25E2%2580%25A2%2509For%2520authors%250A%2509%25E2%2580%25A2%2509Why%2520submit%253F%250A%2509%25E2%2580%25A2%2509Article%2520types%250A%2509%25E2%2580%25A2%2509Author%2520guidelines%250A%2509%25E2%2580%25A2%2509Editor%2520guidelines%250A%2509%25E2%2580%25A2%2509Publishing%2520fees%250A%2509%25E2%2580%25A2%2509Submission%2520checklist%250A%2509%25E2%2580%25A2%2509Contact%2520editorial%2520office%250AAbout%2520us%250AAbout%2520us%250A%2509%25E2%2580%25A2%2509Who%2520we%2520are%250A%2509%25E2%2580%25A2%2509Mission%2520and%2520values%250A%2509%25E2%2580%25A2%2509History%250A%2509%25E2%2580%25A2%2509Leadership%250A%2509%25E2%2580%25A2%2509Awards%250A%2509%25E2%2580%25A2%2509Impact%2520and%2520progress%250A%2509%25E2%2580%25A2%2509Frontiers'%2520impact%250A%2509%25E2%2580%25A2%2509Progress%2520Report%25202022%250A%2509%25E2%2580%25A2%2509All%2520progress%2520reports%250A%2509%25E2%2580%25A2%2509Publishing%2520model%250A%2509%25E2%2580%25A2%2509How%2520we%2520publish%250A%2509%25E2%2580%25A2%2509Open%2520access%250A%2509%25E2%2580%25A2%2509Fee%2520policy%250A%2509%25E2%2580%25A2%2509Peer%2520review%250A%2509%25E2%2580%25A2%2509Research%2520integrity%250A%2509%25E2%2580%25A2%2509Research%2520Topics%250A%2509%25E2%2580%25A2%2509Services%250A%2509%25E2%2580%25A2%2509Societies%250A%2509%25E2%2580%25A2%2509National%2520consortia%250A%2509%25E2%2580%25A2%2509Institutional%2520partnerships%250A%2509%25E2%2580%25A2%2509Collaborators%250A%2509%25E2%2580%25A2%2509More%2520from%2520Frontiers%250A%2509%25E2%2580%25A2%2509Frontiers%2520Forum%250A%2509%25E2%2580%25A2%2509Frontiers%2520Planet%2520Prize%250A%2509%25E2%2580%25A2%2509Press%2520office%250A%2509%25E2%2580%25A2%2509Sustainability%250A%2509%25E2%2580%25A2%2509Career%2520opportunities%250A%2509%25E2%2580%25A2%2509Contact%2520us%250AAll%2520journalsAll%2520articles%2520Submit%2520your%2520research%250AFrontiers%2520in%2520Public%2520Health%250ASections%250ASections%250A%2509%25E2%2580%25A2%2509Aging%2520and%2520Public%2520Health%250A%2509%25E2%2580%25A2%2509Children%2520and%2520Health%250A%2509%25E2%2580%25A2%2509Digital%2520Public%2520Health%250A%2509%25E2%2580%25A2%2509Disaster%2520and%2520Emergency%2520Medicine%250A%2509%25E2%2580%25A2%2509Environmental%2520Health%2520and%2520Exposome%250A%2509%25E2%2580%25A2%2509Health%2520Economics%250A%2509%25E2%2580%25A2%2509Infectious%2520Diseases:%2520Epidemiology%2520and%2520Prevention%250A%2509%25E2%2580%25A2%2509Injury%2520Prevention%2520and%2520Control%250A%2509%25E2%2580%25A2%2509Life-Course%2520Epidemiology%2520and%2520Social%2520Inequalities%2520in%2520Health%250A%2509%25E2%2580%25A2%2509Occupational%2520Health%2520and%2520Safety%250A%2509%25E2%2580%25A2%2509Planetary%2520Health%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520Education%2520and%2520Promotion%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520Policy%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520and%2520Nutrition%250A%2509%25E2%2580%25A2%2509Public%2520Mental%2520Health%250A%2509%25E2%2580%25A2%2509Radiation%2520and%2520Health%250A%2509%25E2%2580%25A2%2509Substance%2520Use%2520Disorders%2520and%2520Behavioral%2520Addictions%250AArticlesResearch%2520TopicsEditorial%2520board%250AAbout%2520journal%250AAbout%2520journal%250A%2509%25E2%2580%25A2%2509Scope%250A%2509%25E2%2580%25A2%2509Field%2520chief%2520editors%250A%2509%25E2%2580%25A2%2509Mission%2520%2526%2520scope%250A%2509%25E2%2580%25A2%2509Facts%250A%2509%25E2%2580%25A2%2509Journal%2520sections%250A%2509%25E2%2580%25A2%2509Open%2520access%2520statement%250A%2509%25E2%2580%25A2%2509Copyright%2520statement%250A%2509%25E2%2580%25A2%2509Quality%250A%2509%25E2%2580%25A2%2509For%2520authors%250A%2509%25E2%2580%25A2%2509Why%2520submit%253F%250A%2509%25E2%2580%25A2%2509Article%2520types%250A%2509%25E2%2580%25A2%2509Author%2520guidelines%250A%2509%25E2%2580%25A2%2509Editor%2520guidelines%250A%2509%25E2%2580%25A2%2509Publishing%2520fees%250A%2509%25E2%2580%25A2%2509Submission%2520checklist%250A%2509%25E2%2580%25A2%2509Contact%2520editorial%2520office%250A%250A%250AFrontiers%2520in%2520Public%2520Health%250A%250ASections%250ASections%250A%2509%25E2%2580%25A2%2509Aging%2520and%2520Public%2520Health%250A%2509%25E2%2580%25A2%2509Children%2520and%2520Health%250A%2509%25E2%2580%25A2%2509Digital%2520Public%2520Health%250A%2509%25E2%2580%25A2%2509Disaster%2520and%2520Emergency%2520Medicine%250A%2509%25E2%2580%25A2%2509Environmental%2520Health%2520and%2520Exposome%250A%2509%25E2%2580%25A2%2509Health%2520Economics%250A%2509%25E2%2580%25A2%2509Infectious%2520Diseases:%2520Epidemiology%2520and%2520Prevention%250A%2509%25E2%2580%25A2%2509Injury%2520Prevention%2520and%2520Control%250A%2509%25E2%2580%25A2%2509Life-Course%2520Epidemiology%2520and%2520Social%2520Inequalities%2520in%2520Health%250A%2509%25E2%2580%25A2%2509Occupational%2520Health%2520and%2520Safety%250A%2509%25E2%2580%25A2%2509Planetary%2520Health%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520Education%2520and%2520Promotion%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520Policy%250A%2509%25E2%2580%25A2%2509Public%2520Health%2520and%2520Nutrition%250A%2509%25E2%2580%25A2%2509Public%2520Mental%2520Health%250A%2509%25E2%2580%25A2%2509Radiation%2520and%2520Health%250A%2509%25E2%2580%25A2%2509Substance%2520Use%2520Disorders%2520and%2520Behavioral%2520Addictions%250AArticlesResearch%2520TopicsEditorial%2520board%250AAbout%2520journal%250AAbout%2520journal%250A%2509%25E2%2580%25A2%2509Scope%250A%2509%25E2%2580%25A2%2509Field%2520chief%2520editors%250A%2509%25E2%2580%25A2%2509Mission%2520%2526%2520scope%250A%2509%25E2%2580%25A2%2509Facts%250A%2509%25E2%2580%25A2%2509Journal%2520sections%250A%2509%25E2%2580%25A2%2509Open%2520access%2520statement%250A%2509%25E2%2580%25A2%2509Copyright%2520statement%250A%2509%25E2%2580%25A2%2509Quality%250A%2509%25E2%2580%25A2%2509For%2520authors%250A%2509%25E2%2580%25A2%2509Why%2520submit%253F%250A%2509%25E2%2580%25A2%2509Article%2520types%250A%2509%25E2%2580%25A2%2509Author%2520guidelines%250A%2509%25E2%2580%25A2%2509Editor%2520guidelines%250A%2509%25E2%2580%25A2%2509Publishing%2520fees%250A%2509%25E2%2580%25A2%2509Submission%2520checklist%250A%2509%25E2%2580%25A2%2509Contact%2520editorial%2520office%250A%250ASubmit%2520%25C2%25A0your%2520research%2520Search%250A%250ADownload%2520article%250A%2509%25E2%2580%25A2%2509Download%2520PDF%250A%2509%25E2%2580%25A2%2509ReadCube%250A%2509%25E2%2580%25A2%2509EPUB%250A%2509%25E2%2580%25A2%2509XML%2520(NLM)%250AShare%2520on%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509%250AExport%2520citation%250A%2509%25E2%2580%25A2%2509EndNote%250A%2509%25E2%2580%25A2%2509Reference%2520Manager%250A%2509%25E2%2580%25A2%2509Simple%2520Text%2520file%250A%2509%25E2%2580%25A2%2509BibTex%250A2,153%250ATotal%2520views%250A229%250ADownloads%250ACitation%2520numbers%2520are%2520available%2520from%2520Dimensions%250AView%2520article%2520impact%250A%250AView%2520altmetric%2520score%250AShare%2520on%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509%250AEdited%2520by%250A%250AFaraz%2520Siddiqui%250AUniversity%2520of%2520York,%2520United%2520Kingdom%250AReviewed%2520by%250A%250AJimmy%2520Chun%2520Yu%2520Louie%250ASchool%2520of%2520Health%2520Sciences,%2520Faculty%2520of%2520Health,%2520Arts%2520and%2520Design,%2520Swinburne%2520University%2520of%2520Technology,%2520Australia%250A%250AElham%2520Jamshidi%250AJohns%2520Hopkins%2520University,%2520United%2520States%250A%250AFarhana%2520Akter%250ADepartment%2520of%2520Endocrinology,%2520Chittagong%2520Medical%2520College,%2520Bangladesh%250ATable%2520of%2520contents%250A%250A%2509%25E2%2580%25A2%2509Abstract%250A%2509%25E2%2580%25A2%2509Introduction%250A%2509%25E2%2580%25A2%2509Methods%250A%2509%25E2%2580%25A2%2509Results%250A%2509%25E2%2580%25A2%2509Discussion%250A%2509%25E2%2580%25A2%2509Conclusion%250A%2509%25E2%2580%25A2%2509Data%2520availability%2520statement%250A%2509%25E2%2580%25A2%2509Ethics%2520statement%250A%2509%25E2%2580%25A2%2509Author%2520contributions%250A%2509%25E2%2580%25A2%2509Funding%250A%2509%25E2%2580%25A2%2509Acknowledgments%250A%2509%25E2%2580%25A2%2509Conflict%2520of%2520interest%250A%2509%25E2%2580%25A2%2509Publisher's%2520note%250A%2509%25E2%2580%25A2%2509Supplementary%2520material%250A%2509%25E2%2580%25A2%2509References%250AExport%2520citation%250A%2509%25E2%2580%25A2%2509EndNote%250A%2509%25E2%2580%25A2%2509Reference%2520Manager%250A%2509%25E2%2580%25A2%2509Simple%2520Text%2520file%250A%2509%25E2%2580%25A2%2509BibTex%250ACheck%2520for%2520updates%250ADownload%2520article%250ADownload%250A%2509%25E2%2580%25A2%2509Download%2520PDF%250A%2509%25E2%2580%25A2%2509ReadCube%250A%2509%25E2%2580%25A2%2509EPUB%250A%2509%25E2%2580%25A2%2509XML%2520(NLM)%250AORIGINAL%2520RESEARCH%2520article%250AFront.%2520Public%2520Health,%252009%2520December%25202024%250ASec.%2520Public%2520Health%2520and%2520Nutrition%250AVolume%252012%2520-%25202024%2520%257C%2520https://doi.org/10.3389/fpubh.2024.1452085%250AThis%2520article%2520is%2520part%2520of%2520the%2520Research%2520Topic%2520Sugar%2520Sweetened%2520Beverage%2520Consumption:%2520Health%2520Implications,%2520Interventions%2520and%2520Future%2520Directions%2520View%2520all%25205%2520articles%250AAdded%2520sugar%2520intake%2520and%2520its%2520associations%2520with%2520incidence%2520of%2520seven%2520different%2520cardiovascular%2520diseases%2520in%252069,705%2520Swedish%2520men%2520and%2520women%250ASuzanne%2520Janzi1*Esther%2520Gonz%25C3%25A1lez-Padilla1Stina%2520Ramne1,2Sara%2520Bergwall3Yan%2520Born%25C3%25A91Emily%2520Sonestedt1%250A%2509%25E2%2580%25A2%25091Nutritional%2520Epidemiology,%2520Department%2520of%2520Clinical%2520Sciences%2520Malm%25C3%25B6,%2520Lund%2520University,%2520Malm%25C3%25B6,%2520Sweden%250A%2509%25E2%2580%25A2%25092Novo%2520Nordisk%2520Foundation%2520Center%2520for%2520Basic%2520Metabolic%2520Research,%2520Faculty%2520of%2520Health%2520and%2520Medical%2520Sciences,%2520University%2520of%2520Copenhagen,%2520Copenhagen,%2520Denmark%250A%2509%25E2%2580%25A2%25093Vascular%2520Diseases,%2520Department%2520of%2520Clinical%2520Sciences%2520Malm%25C3%25B6,%2520Lund%2520University,%2520Malm%25C3%25B6,%2520Sweden%250AIntroduction:%2520The%2520adverse%2520health%2520effects%2520of%2520sugar-sweetened%2520beverage%2520intake%2520are%2520well-established,%2520but%2520the%2520implications%2520of%2520overall%2520added%2520sugar%2520intake%2520remain%2520unclear.%2520We%2520investigated%2520the%2520associations%2520between%2520intake%2520of%2520added%2520sugar%2520and%2520various%2520sugar-sweetened%2520foods%2520and%2520beverages%2520and%2520risk%2520of%25207%2520cardiovascular%2520diseases%2520in%252069,705%2520participants%2520aged%252045%25E2%2580%259383%2520years%2520(47.2%2525%2520female)%2520from%2520the%2520Swedish%2520Mammography%2520cohort%2520and%2520Cohort%2520of%2520Swedish%2520men.%250AMethods:%2520Questionnaire-based%2520diet%2520and%2520lifestyle%2520assessments%2520were%2520administered%2520in%25201997%2520and%25202009.%2520National%2520registers%2520were%2520used%2520for%2520ascertainment%2520of%2520ischemic%2520stroke%2520(n%2520%253D%25206,912),%2520hemorrhagic%2520stroke%2520(n%2520%253D%25201,664),%2520myocardial%2520infarction%2520(n%2520%253D%25206,635),%2520heart%2520failure%2520(n%2520%253D%252010,090),%2520aortic%2520stenosis%2520(n%2520%253D%25201,872),%2520atrial%2520fibrillation%2520(n%2520%253D%252013,167),%2520and%2520abdominal%2520aortic%2520aneurysm%2520(n%2520%253D%25201,575)%2520until%2520December%252031st,%25202019.%2520The%2520associations%2520were%2520studied%2520using%2520Cox%2520regression%2520with%2520time-updated%2520exposure%2520and%2520covariate%2520data.%250AResults:%2520Added%2520sugar%2520intake%2520was%2520positively%2520associated%2520with%2520ischemic%2520stroke%2520and%2520abdominal%2520aortic%2520aneurysm,%2520although%2520the%2520highest%2520risks%2520of%2520most%2520outcomes%2520were%2520found%2520in%2520the%2520lowest%2520intake%2520category.%2520Positive%2520linear%2520associations%2520were%2520found%2520between%2520toppings%2520intake%2520and%2520abdominal%2520aortic%2520aneurysm,%2520and%2520between%2520sweetened%2520beverage%2520intake%2520and%2520ischemic%2520stroke,%2520heart%2520failure,%2520atrial%2520fibrillation,%2520and%2520abdominal%2520aortic%2520aneurysm.%2520Negative%2520linear%2520associations%2520were%2520found%2520between%2520treats%2520intake%2520(pastries,%2520ice%2520cream,%2520chocolate,%2520and%2520sweets)%2520and%2520all%2520outcomes,%2520and%2520between%2520toppings%2520intake%2520(table%2520sugar,%2520honey,%2520jams,%2520and%2520marmalades)%2520and%2520heart%2520failure%2520and%2520aortic%2520stenosis.%250ADiscussion:%2520The%2520findings%2520suggest%2520that%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520cardiovascular%2520diseases%2520vary%2520by%2520disease%2520and%2520source%2520of%2520added%2520sugar.%2520The%2520findings%2520emphasize%2520the%2520adverse%2520health%2520effects%2520of%2520sweetened%2520beverage%2520consumption%2520and%2520indicate%2520higher%2520cardiovascular%2520diseases%2520risks%2520with%2520lower%2520treats%2520intake,%2520which%2520warrants%2520further%2520investigation.%250A%250AIntroduction%250ACardiovascular%2520disease%2520(CVD)%2520comprises%2520various%2520diseases%2520of%2520the%2520heart%2520and%2520blood%2520vessels%2520and%2520is%2520currently%2520the%2520leading%2520cause%2520of%2520death%2520and%2520disease%2520burden%2520in%2520Europe,%2520primarily%2520by%2520stroke%2520and%2520ischemic%2520heart%2520disease%2520(1,%25202).%2520Despite%2520diet%2520being%2520one%2520of%2520the%2520main%2520modifiable%2520risk%2520factors%2520of%2520many%2520CVDs%2520(2),%2520the%2520evidence%2520regarding%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520is%2520scarce%2520and%2520inconclusive%2520(3%25E2%2580%25937).%2520Furthermore,%2520most%2520studies%2520have%2520primarily%2520focused%2520on%2520sugar-sweetened%2520beverage%2520consumption%2520rather%2520than%2520overall%2520added%2520sugar%2520intake%2520even%2520though%2520sugar-sweetened%2520beverages%2520make%2520up%2520only%2520~14%2525%2520of%2520added%2520sugar%2520intake%2520in%2520Sweden%2520and%2520~25%2525%2520in%2520the%2520United%2520States%2520(8,%25209).%250AThe%2520guidelines%2520for%2520sugar%2520intake%2520vary%2520between%2520different%2520authoritative%2520bodies%2520globally,%2520both%2520with%2520regards%2520to%2520the%2520recommendation%2520thresholds%2520and%2520the%2520basis%2520of%2520the%2520guidelines,%2520with%2520some%2520being%2520based%2520mainly%2520on%2520micronutrient%2520dilution%2520(i.e.,%2520the%2520displacement%2520of%2520nutrient-dense%2520food%2520intake%2520by%2520overconsumption%2520of%2520energy-dense%2520foods%2520poor%2520in%2520nutrients),%2520while%2520others%2520are%2520based%2520mainly%2520on%2520the%2520established%2520risks%2520of%2520caries%2520and%2520overweight%2520(6).%2520The%2520Nordic%2520nutrition%2520recommendations%2520recommend%2520limiting%2520added%2520sugar%2520and%2520free%2520sugar%2520(all%2520added%2520sugar%2520as%2520well%2520as%2520naturally%2520occurring%2520sugars%2520in%2520honey,%2520syrups,%2520fruit%2520juices,%2520and%2520fruit%2520juice%2520concentrates)%2520intake%2520to%2520%253C%252010%2525%2520of%2520energy%2520intake%2520(E%2525),%2520based%2520on%2520the%2520risk%2520of%2520micronutrient%2520dilution%2520and%2520developing%2520chronic%2520metabolic%2520diseases%2520and%2520dental%2520caries%2520(10).%2520The%2520American%2520dietary%2520guidelines%2520have%2520a%2520similar%2520recommendation%2520for%2520added%2520sugar%2520intake%2520based%2520on%2520the%2520risk%2520of%2520micronutrient%2520dilution,%2520overweight%2520and%2520obesity,%2520as%2520well%2520as%2520related%2520chronic%2520metabolic%2520diseases%2520(11),%2520and%2520The%2520World%2520Health%2520Organization%2520has%2520a%2520similar%2520recommendation%2520for%2520free%2520sugar%2520intake%2520based%2520on%2520the%2520risk%2520of%2520dental%2520caries%2520and%2520overweight.%2520The%2520World%2520Health%2520Organization%2520also%2520further%2520suggest%2520reducing%2520the%2520intake%2520to%2520below%25205%2520E%2525%2520for%2520additional%2520benefits%2520for%2520dental%2520health%2520(12).%250AThe%2520European%2520Food%2520Safety%2520Authority's%2520(EFSA)%2520scientific%2520opinion%2520on%2520a%2520tolerable%2520upper%2520intake%2520level%2520for%2520dietary%2520sugars%2520published%2520in%25202022%2520(6)%2520reported%2520moderate%2520evidence%2520for%2520a%2520dose-response%2520relationship%2520between%2520added%2520and%2520free%2520sugar%2520intake%2520and%2520obesity%2520and%2520dyslipidemia,%2520as%2520well%2520as%2520evidence%2520of%2520high%2520certainty%2520pointing%2520toward%2520associations%2520between%2520intake%2520of%2520sugar-sweetened%2520beverages%2520and%2520obesity,%2520type%25202%2520diabetes,%2520hypertension,%2520and%2520CVD%2520incidence.%2520However,%2520no%2520conclusion%2520could%2520be%2520drawn%2520about%2520the%2520associations%2520between%2520added%2520and%2520free%2520sugar%2520intake%2520and%2520CVD%2520risk%2520due%2520to%2520the%2520lack%2520of%2520studies%2520available%2520(6).%250AMost%2520studies%2520on%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520have%2520studied%2520CVD%2520as%2520a%2520composite%2520endpoint,%2520but%2520previous%2520findings%2520of%2520ours%2520indicate%2520that%2520the%2520association%2520between%2520added%2520sugar%2520and%2520CVD%2520incidence%2520varies%2520between%2520different%2520CVDs%2520(13),%2520thus%2520highlighting%2520the%2520importance%2520of%2520studying%2520different%2520CVDs%2520separately.%2520Research%2520on%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520most%2520individual%2520CVDs%2520such%2520as%2520for%2520example%2520abdominal%2520aortic%2520aneurysm%2520and%2520atrial%2520fibrillation%2520is%2520lacking,%2520and%2520the%2520very%2520few%2520studies%2520that%2520have%2520investigated%2520the%2520associations%2520with%2520for%2520example%2520myocardial%2520infarction%2520or%2520stroke%2520present%2520inconsistent%2520findings%2520(13%25E2%2580%259315).%2520In%2520addition%2520to%2520the%2520lack%2520of%2520studies%2520investigating%2520the%2520long-term%2520effects%2520of%2520added%2520sugar%2520intake%2520and%2520the%2520insufficient%2520evidence%2520regarding%2520overall%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520(3,%252016),%2520many%2520studies%2520only%2520include%2520a%2520single%2520dietary%2520assessment%2520at%2520baseline,%2520meaning%2520that%2520the%2520assumption%2520has%2520to%2520be%2520made%2520that%2520this%2520single%2520assessment%2520is%2520representative%2520of%2520the%2520participants'%2520diets%2520over%2520time.%2520In%2520this%2520study,%2520diet%2520was%2520assessed%2520at%2520two%2520time-points%2520(in%2520years%25201997%2520and%25202009)%2520for%2520the%2520majority%2520of%2520the%2520participants.%250AThe%2520purpose%2520of%2520this%2520study%2520was%2520therefore%2520to%2520examine%2520whether%2520there%2520are%2520associations%2520between%2520intake%2520of%2520added%2520sugar,%2520sugar-sweetened%2520foods%2520and%2520beverages,%2520and%2520risk%2520of%2520several%2520types%2520of%2520CVD%2520(i.e.,%2520ischemic%2520stroke,%2520hemorrhagic%2520stroke,%2520myocardial%2520infarction,%2520heart%2520failure,%2520aortic%2520stenosis,%2520atrial%2520fibrillation,%2520and%2520abdominal%2520aortic%2520aneurysm)%2520among%252069,705%2520participants%2520in%2520two%2520Swedish%2520cohorts,%2520with%2520time-updated%2520data%2520for%2520a%2520majority%2520of%2520the%2520participants%2520in%2520the%2520study.%2520Discerning%2520whether%2520there%2520are%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520could%2520help%2520inform%2520future%2520nutritional%2520recommendations.%250AMethods%250AStudy%2520population%250AThe%2520study%2520population%2520consists%2520of%2520female%2520participants%2520from%2520the%2520Swedish%2520Mammography%2520Cohort%2520(SMC)%2520and%2520male%2520participants%2520from%2520the%2520Cohort%2520of%2520Swedish%2520Men%2520(COSM),%2520both%2520of%2520which%2520are%2520population%25E2%2580%2593based%2520prospective%2520cohort%2520studies%2520in%2520Central%2520Sweden%2520and%2520part%2520of%2520the%2520national%2520research%2520infrastructure%2520SIMPLER%2520(Swedish%2520Infrastructure%2520for%2520Medical%2520Population-based%2520Life-course%2520Environmental%2520Research).%2520Invitations%2520were%2520sent%2520by%2520mail%2520to%2520all%2520women%2520born%2520between%25201914%25E2%2580%25931948%2520living%2520in%2520Uppsala%2520county%2520and%2520V%25C3%25A4stmanland%2520county,%2520and%2520to%2520all%2520men%2520born%2520between%25201918%25E2%2580%25931952%2520living%2520in%2520%25C3%2596rebro%2520county%2520and%2520V%25C3%25A4stmanland%2520county%2520(17).%250AThe%2520participants%2520of%2520SMC%2520and%2520COSM%2520completed%2520identical%2520questionnaires%2520(except%2520for%2520some%2520sex-specific%2520questions)%2520regarding%2520diet,%2520health,%2520and%2520lifestyle%2520factors%2520in%2520the%2520years%25201987%25E2%2580%25931990%2520(SMC%2520only),%25201997,%25202008,%2520and%25202009.%2520Ultimately,%252066,651%2520women%2520participated%2520in%2520SMC%2520in%25201987%25E2%2580%25931990%2520(74%2525%2520response%2520rate).%2520During%25201997,%2520which%2520serves%2520as%2520the%2520baseline%2520of%2520our%2520study%2520as%2520it%2520was%2520the%2520first%2520assessment%2520that%2520included%2520both%2520cohorts,%2520the%2520response%2520rate%2520was%252070%2525%2520of%2520the%2520still%2520living%2520participants%2520from%25201987%2520in%2520SMC%2520(n%2520%253D%252039,227),%2520and%252049%2525%2520in%2520COSM%2520(n%2520%253D%252048,850)%2520(17).%2520The%2520study%2520was%2520approved%2520by%2520The%2520Swedish%2520Ethical%2520Review%2520Authority%2520(dnr:%25202019-03986)%2520and%2520completion%2520of%2520the%2520self-administered%2520questionnaire%2520was%2520considered%2520to%2520convey%2520informed%2520consent.%250AIn%25202008,%2520all%2520participants%2520of%2520SMC%2520and%2520COSM%2520were%2520sent%2520a%2520health%2520and%2520lifestyle%2520questionnaire,%2520and%2520those%2520who%2520responded%2520received%2520an%2520expanded%2520semiquantitative%2520food%2520frequency%2520questionnaire%2520(FFQ)%2520in%25202009.%2520In%2520total,%252047,918%2520participants%2520responded%2520to%2520the%25202009%2520questionnaire,%2520and%252042,327%2520participants%2520(19,598%2520women%2520and%252022,729%2520men)%2520remained%2520after%2520baseline%2520exclusions%2520(61%2525%2520of%2520participants%2520from%25201997)%2520(Figure%25201).%250A%250AFigure%25201%250AFigure%25201.%2520Description%2520of%2520the%2520study%2520population,%2520exclusions,%2520and%2520statistical%2520analyses%2520(with%2520the%2520black%2520arrows%2520representing%2520the%2520main%2520analyses,%2520and%2520the%2520gray%2520arrows%2520representing%2520the%2520sensitivity%2520analyses).%2520*Prevalent%2520cases%2520of%2520ischemic%2520stroke,%2520intracerebral%2520hemorrhage,%2520subarachnoid%2520hemorrhage,%2520myocardial%2520infarction,%2520heart%2520failure,%2520atrial%2520fibrillation,%2520aortic%2520valve%2520stenosis,%2520and%2520abdominal%2520aortic%2520aneurysm.%2520BMI,%2520Body%2520Mass%2520Index;%2520COSM,%2520Cohort%2520of%2520Swedish%2520men;%2520SMC,%2520Swedish%2520mammography%2520cohort;%2520FFQ,%2520Food%2520frequency%2520questionnaire;%2520CVD,%2520Cardiovascular%2520disease.%250A%250A%250ABaseline%2520exclusions%250AAs%2520SMC%2520originally%2520only%2520included%2520women%2520without%2520cancer,%2520participants%2520in%2520both%2520cohorts%2520with%2520cancer%2520recorded%2520in%2520Swedish%2520registers%2520prior%2520to%2520the%2520baseline%2520were%2520excluded%2520from%2520the%2520present%2520study.%2520Further%2520exclusions%2520were%2520made%2520of%2520those%2520with%2520prevalent%2520CVD%2520(identified%2520using%2520national%2520registers),%2520self-reported%2520diabetes%2520at%2520baseline,%2520death%2520prior%2520to%2520January%25201st,%25201998,%2520missing%2520or%2520incorrect%2520ID,%2520and%2520those%2520deemed%2520to%2520have%2520had%2520extreme%2520energy%2520intakes,%2520since%2520it%2520could%2520indicate%2520misreporting.%2520Extreme%2520energy%2520intake%2520was%2520defined%2520as%2520being%2520outside%2520of%25203%2520standard%2520deviations%2520(SDs)%2520below%2520and%2520above%2520the%2520loge-transformed%2520mean%2520energy%2520intake,%2520corresponding%2520to%2520below%2520470%2520kcal%2520and%2520above%252012,790%2520kcal%2520in%2520COSM%2520and%2520below%2520263%2520kcal%2520and%2520above%25209,647%2520kcal%2520in%2520SMC.%2520Thus,%252032,934%2520participants%2520from%2520SMC%2520and%252036,771%2520participants%2520from%2520COSM%2520remained%2520(69,705%2520participants%2520in%2520total)%2520in%25201997.%2520For%2520the%2520assessment%2520in%25202009,%2520individuals%2520deemed%2520to%2520have%2520had%2520extreme%2520energy%2520intakes%2520(i.e.,%2520outside%2520of%25203%2520SDs%2520below%2520and%2520above%2520the%2520loge-transformed%2520mean%2520energy%2520intake,%2520corresponding%2520to%2520below%2520580%2520kcal%2520and%2520above%25205,687%2520kcal%2520in%2520SMC%2520and%2520below%2520787%2520kcal%2520and%2520above%25207,932%2520kcal%2520in%2520COSM)%2520were%2520excluded,%2520resulting%2520in%252019,598%2520participants%2520in%2520SMC%2520and%252022,729%2520participants%2520in%2520COSM%2520remaining.%2520In%2520total,%252042,327%2520participants%2520responded%2520to%2520the%25202009%2520questionnaire%2520and%2520remained%2520after%2520exclusions%2520(Figure%25201).%250ADietary%2520assessment%250ADietary%2520information%2520at%2520baseline%2520(in%25201997)%2520was%2520obtained%2520using%2520a%252096-item%2520validated%2520semi-quantitative%2520FFQ%2520covering%2520average%2520intakes%2520of%2520various%2520foods%2520and%2520beverages%2520during%2520the%2520preceding%2520year.%2520For%2520all%2520food%2520items%2520and%2520for%2520alcohol%2520intake,%2520the%2520participants%2520could%2520choose%2520between%25208%2520or%25209%2520predetermined%2520consumption%2520frequencies,%2520and%2520portion%2520sizes%2520were%2520either%2520specified%2520as%2520standardized%2520portions%2520or%2520self-reported%2520(as%2520was%2520the%2520case%2520for%2520alcohol%2520consumption).%2520The%2520questions%2520regarding%2520frequency%2520of%2520beverage%2520consumption%2520(including%2520sweetened%2520beverages,%2520tea,%2520and%2520coffee)%2520and%2520table%2520sugar%2520and%2520honey%2520intakes%2520were%2520posed%2520as%2520open-ended%2520questions%2520about%2520the%2520number%2520of%2520daily%2520or%2520weekly%2520servings%2520consumed%2520in%2520the%2520preceding%2520year.%250AIn%25202009,%2520a%2520132-item%2520semi-quantitative%2520FFQ%2520was%2520distributed%2520to%2520COSM%2520and%2520SMC%2520participants%2520in%2520order%2520to%2520obtain%2520updated%2520dietary%2520information.%2520The%2520132-item%2520FFQ%2520included%2520additional%2520foods%2520and%2520was%2520designed%2520to%2520capture%2520the%2520consumption%2520of%2520specific%2520foods%2520and%2520diets%2520that%2520were%2520consumed%2520more%2520frequently%2520in%25202009%2520than%2520in%25201997.%2520Nutrient%2520intakes%2520were%2520estimated%2520by%2520multiplying%2520the%2520consumption%2520frequency%2520of%2520each%2520food%2520item%2520with%2520the%2520nutrient%2520content%2520of%2520sex-%2520and%2520age-specific%2520portion%2520sizes%2520obtained%2520from%2520weighed%2520food%2520records%2520in%2520a%2520subgroup%2520of%2520152%2520men%2520from%2520COSM%2520and%2520129%2520women%2520from%2520SMC.%2520The%2520nutrient%2520values%2520were%2520derived%2520from%2520the%2520Swedish%2520Food%2520Composition%2520Database%2520(18).%2520Participants%2520with%2520missing%2520information%2520about%2520individual%2520foods%2520were%2520interpreted%2520as%2520non-consumers.%250AThe%25201997%2520dietary%2520assessment%2520was%2520validated%2520against%252014%252024-h%2520recall%2520interviews%2520among%2520248%2520Swedish%2520men%2520living%2520in%2520central%2520Sweden,%2520randomly%2520selected%2520from%2520the%2520Swedish%2520population%2520register,%2520with%2520a%2520Spearman%2520rank%2520correlation%2520coefficient%2520of%25200.70%2520being%2520reported%2520for%2520sucrose%2520(19).%2520Further,%2520a%2520validation%2520study%2520was%2520carried%2520out%2520among%2520129%2520randomly%2520selected%2520women%2520from%2520SMC%2520using%2520four%25201-week%2520records%2520that%2520were%2520completed%25203%25E2%2580%25934%2520months%2520apart.%2520The%2520reported%2520correlation%2520coefficients%2520were%25200.6%2520for%2520sweetened%2520beverages,%25200.5%2520for%2520jams%2520and%2520marmalades,%2520and%25200.4%2520for%2520sweets%2520(A.%2520Wolk,%2520unpublished%2520observations,%25201992).%250AAdded%2520sugar%2520estimation%250AThe%2520participants'%2520total%2520added%2520sugar%2520intakes%2520were%2520estimated%2520by%2520subtracting%2520their%2520intakes%2520of%2520naturally%2520occurring%2520sugars%2520in%2520fruit,%2520vegetables,%2520fruit%2520juices,%2520and%2520jams%2520from%2520their%2520total%2520intake%2520of%2520sucrose%2520and%2520monosaccharides.%2520The%2520amounts%2520of%2520naturally%2520occurring%2520monosaccharides%2520and%2520sucrose%2520were%2520estimated%2520using%2520the%2520Swedish%2520Food%2520Composition%2520Database%2520(18)%2520(Supplementary%2520Table%2520S1).%2520The%2520added%2520sugar%2520intakes%2520(g/day)%2520were%2520then%2520converted%2520into%2520percentages%2520of%2520non-alcoholic%2520energy%2520intakes.%2520This%2520added%2520sugar%2520density%2520variable%2520was%2520further%2520categorized%2520into%2520%25E2%2589%25A4%25205%2520E%2525,%2520%253E5%25E2%2580%25937.5%2520E%2525,%2520%253E7.5%25E2%2580%259310%2520E%2525,%2520%253E10%25E2%2580%259315%2520E%2525,%2520%253E15%25E2%2580%259320%2520E%2525,%2520and%2520%253E20%2520E%2525.%2520The%2520categories%2520were%2520designed%2520to%2520allow%2520a%2520wide%2520range%2520of%2520sugar%2520intakes%2520to%2520be%2520studied,%2520including%2520those%2520commonly%2520used%2520in%2520nutritional%2520recommendations%2520as%2520well%2520as%2520extreme%2520intakes.%250ASugar-sweetened%2520foods%2520and%2520beverages%250AAs%2520the%2520macronutrient%2520distribution,%2520energy%2520density,%2520and%2520consumption%2520patterns%2520vary%2520between%2520different%2520sources%2520of%2520added%2520sugar,%2520sugar-sweetened%2520foods%2520and%2520beverages%2520were%2520studied%2520in%2520groups%2520of%2520treats%2520(pastries,%2520ice%2520cream,%2520sweets,%2520and%2520chocolate),%2520toppings%2520(table%2520sugar,%2520honey,%2520jams,%2520and%2520marmalades),%2520and%2520sweetened%2520beverages%2520(all%2520sweetened%2520sodas%2520and%2520fruit%2520drinks%2520but%2520not%2520pure%2520fruit%2520juices).%2520Notable%2520differences%2520are%2520that%2520toppings%2520generally%2520have%2520negligible%2520fat%2520and%2520protein%2520contents,%2520whereas%2520treats%2520tend%2520to%2520have%2520a%2520higher%2520fat%2520content,%2520and%2520we%2520additionally%2520hypothesized%2520that%2520treats%2520were%2520more%2520likely%2520to%2520be%2520overconsumed%2520than%2520toppings.%2520As%2520liquid%2520sugar%2520has%2520been%2520suggested%2520to%2520be%2520metabolized%2520differently%2520than%2520solid%2520sugar%2520and%2520to%2520consequently%2520cause%2520different%2520health%2520outcomes%2520(20),%2520a%2520category%2520of%2520sweetened%2520beverages%2520was%2520also%2520created.%2520The%2520dietary%2520questionnaire%2520from%25201997%2520asked%2520about%2520overall%2520sweetened%2520beverage%2520intake,%2520while%2520the%25202009%2520questionnaire%2520differentiated%2520between%2520sugar-sweetened%2520beverages%2520and%2520artificially%2520sweetened%2520beverages,%2520which%2520were%2520combined%2520to%2520create%2520the%2520sweetened%2520beverage%2520variable%2520in%2520the%25202009%2520data.%2520Participants%2520with%2520missing%2520information%2520about%2520individual%2520foods%2520were%2520interpreted%2520as%2520non-consumers%2520(Supplementary%2520Table%2520S2).%250AIntake%2520of%2520sweetened%2520beverages%2520was%2520divided%2520into%2520categories%2520of%2520%25E2%2589%25A4%25201,%2520%253E1%25E2%2580%25933,%2520%253E3%25E2%2580%25935,%2520%253E5%25E2%2580%25938,%2520and%2520%253E8%2520servings/week,%2520intake%2520of%2520treats%2520was%2520divided%2520into%2520categories%2520of%2520%25E2%2589%25A4%25202,%2520%253E2%25E2%2580%25935,%2520%253E5%25E2%2580%25938,%2520%253E8%25E2%2580%259314,%2520and%2520%253E14%2520servings/week,%2520and%2520intake%2520of%2520toppings%2520was%2520divided%2520into%2520categories%2520of%2520%25E2%2589%25A4%25202,%2520%253E2%25E2%2580%25937,%2520%253E7%25E2%2580%259314,%2520%253E14%25E2%2580%259328,%2520and%2520%253E28%2520servings/week.%2520The%2520categories%2520for%2520the%2520sugar-sweetened%2520foods%2520and%2520beverages%2520were%2520set%2520based%2520on%2520categories%2520previously%2520used%2520in%2520two%2520other%2520Swedish%2520cohorts%2520carried%2520out%2520around%2520the%2520same%2520period%2520as%2520the%2520baseline%2520of%2520COSM%2520and%2520SMC,%2520and%2520were%2520determined%2520by%2520examining%2520the%2520restricted%2520cubic%2520spline%2520curves%2520of%2520association%2520between%2520added%2520sugar%2520intake%2520and%2520total%2520mortality%2520(21,%252022).%250ACase%2520ascertainment%250AThe%2520participants%2520were%2520followed%2520until%2520diagnosis%2520of%2520the%2520studied%2520outcome,%2520death,%2520or%2520the%2520end%2520of%2520the%2520follow-up%2520period%2520(December%252031st,%25202019),%2520whichever%2520occurred%2520first.%2520The%2520participants'%2520Swedish%2520personal%2520identification%2520numbers%2520were%2520used%2520to%2520identify%2520cases%2520of%2520the%2520studied%2520outcomes%2520between%25201998%2520and%25202019%2520in%2520the%2520Swedish%2520National%2520Inpatient%2520Register%2520and%2520the%2520Cause%2520of%2520Death%2520Register,%2520according%2520to%2520the%2520International%2520Classification%2520of%2520Diseases%252010%2520(ICD%25E2%2588%259210)%2520and%2520corresponding%2520codes%2520in%2520earlier%2520editions.%2520The%2520Swedish%2520National%2520Inpatient%2520Register%2520has%2520been%2520reported%2520to%2520have%2520high%2520diagnostic%2520validity,%2520with%2520positive%2520predictive%2520values%2520of%2520%253E90%2525%2520being%2520reported%2520for%2520most%2520of%2520the%2520studied%2520outcomes%2520(23).%2520The%2520studied%2520outcomes%2520and%2520their%2520ICD-10%2520codes%2520were%2520ischemic%2520stroke%2520(I63),%2520myocardial%2520infarction%2520(I21),%2520heart%2520failure%2520(I50%2520and%2520I11.0),%2520atrial%2520fibrillation%2520(I48),%2520aortic%2520valve%2520stenosis%2520(I35.0%2520and%2520I35.2),%2520and%2520abdominal%2520aortic%2520aneurysm%2520(I71.3%2520and%2520I71.4).%2520As%2520it%2520has%2520been%2520indicated%2520that%2520ischemic%2520stroke%2520incidence%2520is%2520affected%2520more%2520by%2520lifestyle%2520factors%2520than%2520hemorrhagic%2520stroke%2520(24),%2520ischemic%2520stroke%2520cases%2520and%2520hemorrhagic%2520stroke%2520cases%2520were%2520studied%2520separately,%2520with%2520the%2520variable%2520for%2520hemorrhagic%2520stroke%2520including%2520cases%2520of%2520intracerebral%2520hemorrhage%2520(I61)%2520and%2520subarachnoid%2520hemorrhage%2520(I60).%250AStatistical%2520analyses%250AAll%2520analyses%2520were%2520conducted%2520using%2520R%2520version%25204.0.3%2520(R%2520Foundation%2520for%2520Statistical%2520Computing,%2520Vienna,%2520Austria),%2520with%2520P%25E2%2580%2593values%2520%253C%25200.05%2520denoting%2520statistical%2520significance.%2520The%2520population%2520baseline%2520characteristics%2520were%2520tested%2520across%2520the%2520added%2520sugar%2520intake%2520categories,%2520with%2520normally%2520distributed%2520continuous%2520variables%2520presented%2520as%2520mean%2520with%2520SD,%2520skewed%2520continuous%2520variables%2520presented%2520as%2520median%2520with%2520interquartile%2520range%2520(IQR),%2520and%2520categorical%2520variables%2520presented%2520as%2520number%2520of%2520participants%2520with%2520proportion%2520of%2520total%2520participants.%250ACox%2520proportional%2520hazards%2520regression%2520models%2520were%2520used%2520to%2520investigate%2520the%2520associations%2520between%2520the%2520studied%2520exposures%2520and%2520outcomes%2520using%2520the%2520survival%2520R%2520package%2520(25)%2520with%2520the%2520time%2520of%2520follow-up%2520being%2520used%2520as%2520the%2520time%2520variable.%2520Time-updated%2520exposures%2520and%2520covariates%2520were%2520incorporated%2520in%2520the%2520Cox%2520regression%2520for%2520participants%2520who%2520responded%2520to%2520both%2520the%25201997%2520and%25202009%2520questionnaires%2520(n%2520%253D%252042,327).%2520This%2520was%2520done%2520by%2520dividing%2520the%2520follow-up%2520period%2520into%2520two%2520intervals%2520(1997%25E2%2580%25932009%2520and%25202009%25E2%2580%25932019),%2520with%2520the%25201997%2520data%2520being%2520used%2520in%2520the%2520first%2520interval%2520and%2520the%2520updated%2520data%2520from%25202009%2520being%2520used%2520in%2520the%2520second%2520interval.%2520For%2520those%2520who%2520only%2520completed%2520the%25201997%2520questionnaires%2520(n%2520%253D%252027,378),%2520the%2520data%2520from%25201997%2520was%2520used%2520in%2520both%2520intervals%2520(Figure%25201).%2520The%2520P-values%2520for%2520the%2520trends%2520were%2520analyzed%2520using%2520the%2520medians%2520of%2520the%2520exposure%2520categories%2520in%2520the%2520models,%2520using%2520the%2520lowest%2520intake%2520category%2520as%2520a%2520reference.%250AAssociations%2520between%2520added%2520sugar%2520intake%2520and%2520incident%2520disease%2520outcomes%2520were%2520investigated%2520using%2520several%2520different%2520models%2520that%2520were%2520adjusted%2520for%2520factors%2520that%2520are%2520established%2520risk%2520factors%2520for%2520CVDs%2520and%2520are%2520associated%2520with%2520added%2520sugar%2520intake.%2520The%2520first%2520model%2520was%2520adjusted%2520for%2520age%2520(years),%2520sex,%2520and%2520total%2520energy%2520intake%2520(kilocalories/day).%2520The%2520second%2520model%2520was%2520additionally%2520adjusted%2520for%2520lifestyle%2520factors%2520as%2520categorical%2520variables:%2520smoking%2520status%2520%255Bcurrent,%2520former,%2520never,%2520missing%2520(n1997%2520%253D%25201,086,%2520n2009%2520%253D%25201,218)%255D,%2520educational%2520level%2520%255Bless%2520than%2520high%2520school,%2520high%2520school,%2520university,%2520missing%2520(n1997%2520%253D%2520279,%2520n2009%2520%253D%252088)%255D,%2520alcohol%2520consumption%2520(non-consumers%2520and%2520quintiles%2520of%2520sex-specific%2520intakes),%2520as%2520well%2520as%2520walking/cycling%2520%255Balmost%2520never,%2520%253C%252020%2520min/day,%252020%25E2%2580%259340%2520min/day,%252040%25E2%2580%259360%2520min/day,%25201%25E2%2580%25931.5%2520h/day,%2520%253E1.5%2520h/day,%2520missing%2520(n1997%2520%253D%25206,084,%2520n2009%2520%253D%2520676)%255D,%2520and%2520exercise%2520(type%2520of%2520exercise%2520not%2520specified)%2520%255B%2520%253C%25201%2520h/week,%25201%25E2%2580%25932%2520h/week,%25203%25E2%2580%25934%2520h/week%2520or%2520%25E2%2589%25A55%2520h/week,%2520missing%2520(n1997%2520%253D%25207,385,%2520n2009%2520%253D%2520917)%255D.%2520The%2520smoking%2520variable%2520was%2520modified%2520so%2520that%2520all%2520participants%2520who%2520indicated%2520years%2520since%2520they%2520stopped%2520smoking%2520were%2520recorded%2520as%2520former%2520smokers.%2520The%2520main%2520model%2520was%2520additionally%2520adjusted%2520for%2520body%2520mass%2520index%2520(BMI)%2520(kg/m2)%2520and%2520dietary%2520factors,%2520including%2520consumption%2520of%2520processed%2520meat%2520(g/day),%2520coffee%2520(g/day),%2520as%2520well%2520as%2520energy%2520adjusted%2520saturated%2520fatty%2520acid%2520and%2520fiber%2520intakes%2520(using%2520the%2520nutrient%2520residual%2520model).%2520The%2520proportional%2520hazards%2520assumptions%2520were%2520tested%2520using%2520Schoenfeld%2520residuals,%2520and%2520the%2520models%2520were%2520stratified%2520for%2520age,%2520sex,%2520and%2520walking/cycling%2520to%2520attain%2520proportionality.%2520Missing%2520values%2520were%2520included%2520as%2520a%2520separate%2520category%2520for%2520each%2520of%2520the%2520categorical%2520variables,%2520while%2520missing%2520values%2520for%2520continuous%2520dietary%2520covariates%2520were%2520interpreted%2520as%2520zero-consumption.%2520Non-linear%2520trends%2520of%2520CVDs%2520were%2520assessed%2520using%2520restricted%2520cubic%2520splines%2520and%2520the%2520rms%2520R%2520package%2520with%25205%2520knots%2520placed%2520at%2520the%25205th,%252027.5th,%252050th,%252072.5th,%2520and%252095th%2520percentiles%2520of%2520added%2520sugar%2520intake%2520with%252010%2520E%2525%2520as%2520reference%2520(26).%250ASensitivity%2520analyses%250AInteractions%2520between%2520sex%2520and%2520added%2520sugar%2520intake,%2520as%2520well%2520as%2520BMI%2520and%2520added%2520sugar%2520intake,%2520were%2520studied%2520by%2520adding%2520them%2520as%2520continuous%2520interaction%2520terms%2520in%2520the%2520main%2520model%2520for%2520each%2520of%2520the%2520outcomes.%2520For%2520the%2520associations%2520with%2520statistically%2520significant%2520interactions,%2520stratified%2520analyses%2520were%2520conducted.%250ASince%2520the%25201997%2520questionnaire%2520only%2520asked%2520about%2520overall%2520sweetened%2520beverage%2520intake%2520(i.e.,%2520sugar-sweetened%2520beverages%2520and%2520artificially%2520sweetened%2520beverages%2520combined),%2520dietary%2520data%2520from%25202009%2520was%2520used%2520to%2520study%2520consumption%2520of%2520artificially%2520sweetened%2520beverages%2520and%2520sugar-sweetened%2520beverages%2520separately,%2520using%25202009%2520as%2520a%2520baseline,%2520among%2520participants%2520who%2520responded%2520to%2520the%25202009%2520questionnaire%2520(n%2520%253D%252042,327).%250AComorbidities%2520are%2520prevalent%2520with%2520many%2520CVDs%2520(27,%252028).%2520To%2520take%2520comorbidity%2520into%2520consideration,%2520a%2520sensitivity%2520analysis%2520was%2520conducted%2520in%2520which%2520all%2520participants%2520with%2520incidence%2520of%2520any%2520of%2520the%2520other%2520studied%2520CVDs%2520prior%2520to%2520incidence%2520of%2520the%2520outcome%2520of%2520interest%2520were%2520excluded%2520from%2520the%2520analysis.%250AAs%2520there%2520are%2520several%2520different%2520methods%2520for%2520energy%2520adjustment%2520in%2520epidemiological%2520studies%2520(29),%2520sensitivity%2520analyses%2520were%2520conducted%2520using%2520additional%2520energy-adjustment%2520methods.%2520For%2520added%2520sugar,%2520the%2520residual%2520method%2520were%2520used%2520in%2520addition%2520to%2520the%2520nutrient%2520density%2520method%2520(as%2520used%2520in%2520the%2520main%2520analyses)%2520(29).%2520For%2520sugar-sweetened%2520foods%2520and%2520beverages,%2520the%2520nutrient%2520density%2520method%2520and%2520the%2520residual%2520method%2520were%2520used%2520in%2520addition%2520to%2520the%2520standard%2520multivariate%2520method%2520(as%2520used%2520in%2520the%2520main%2520analyses).%2520The%2520energy-adjusted%2520intakes%2520using%2520the%2520nutrient%2520density%2520method%2520and%2520the%2520residual%2520method%2520were%2520standardized%2520to%2520the%2520study%2520population's%2520mean%2520energy%2520intake.%250ATo%2520evaluate%2520how%2520the%2520addition%2520of%2520the%25202009%2520diet%2520assessment%2520affected%2520the%2520risk%2520estimates%2520in%2520the%2520main%2520analyses%2520for%2520added%2520sugar%2520intake,%2520a%2520sensitivity%2520analysis%2520using%2520only%2520the%25201997%2520baseline%2520dietary%2520data%2520was%2520conducted.%250AFurther,%2520to%2520reduce%2520bias%2520by%2520reverse%2520causality,%2520a%2520sensitivity%2520analysis%2520was%2520conducted%2520where%2520we%2520excluded%2520cases%2520of%2520the%2520studied%2520outcome%2520that%2520occurred%2520within%2520the%2520first%25203%2520years%2520of%2520the%2520follow-up%2520period.%250AFinally,%2520to%2520investigate%2520how%2520including%2520missing%2520data%2520may%2520have%2520affected%2520the%2520results%2520for%2520added%2520sugar,%2520we%2520conducted%2520a%2520sensitivity%2520analysis%2520in%2520which%2520only%2520participants%2520with%2520complete%2520data%2520for%2520all%2520sugar-sweetened%2520foods%2520and%2520beverages%2520and%2520categorical%2520covariates%2520were%2520included.%2520Similarly,%2520we%2520conducted%2520sensitivity%2520analyses%2520for%2520treats,%2520toppings,%2520and%2520sweetened%2520beverage%2520intake,%2520including%2520only%2520participants%2520with%2520complete%2520data%2520for%2520the%2520respective%2520variables%2520and%2520categorical%2520covariates.%250AResults%250AStudy%2520population%2520characteristics%250AThe%2520study%2520population%2520consisted%2520of%252069,705%2520participants%2520(47.2%2525%2520female),%2520with%2520a%2520mean%2520BMI%2520of%252025.3%2520kg/m2,%2520mean%2520age%2520of%252059.9%2520years%2520(ranging%2520between%252045%2520and%252083%2520years)%2520and%2520mean%2520added%2520sugar%2520intake%2520of%25209.1%2520E%2525%2520at%2520baseline%2520(Table%25201).%2520Higher%2520added%2520sugar%2520consumers%2520tended%2520to%2520be%2520male,%2520with%2520higher%2520exercise%2520levels%2520and%2520with%2520lower%2520education%2520levels%2520than%2520lower%2520added%2520sugar%2520consumers.%2520Furthermore,%2520those%2520consuming%2520high%2520amounts%2520of%2520added%2520sugar%2520were%2520generally%2520older,%2520had%2520higher%2520energy%2520intakes,%2520and%2520had%2520higher%2520intakes%2520of%2520toppings%2520and%2520sweetened%2520beverages.%2520The%2520intake%2520of%2520treats%2520was%2520more%2520evenly%2520distributed%2520across%2520the%2520added%2520sugar%2520intake%2520groups%2520than%2520the%2520other%2520sugar-sweetened%2520foods%2520and%2520beverages%2520(Table%25202).%250A%250ATable%25201%250ATable%25201.%2520Reported%2520dietary%2520intakes%2520in%2520SMC%2520and%2520COSM%2520in%25201997%2520and%25202009%2520shown%2520in%2520men%2520and%2520women%2520separately%2520as%2520well%2520as%2520combined.%250A%250A%250ATable%25202%250ATable%25202.%2520Baseline%2520characteristics%2520of%2520the%2520study%2520population%2520according%2520to%2520the%2520added%2520sugar%2520intake%2520categories.%250A%250A%250AAdded%2520sugar%2520intake%2520and%2520CVD%2520risk%250ADuring%2520the%2520follow-up%2520period,%252025,739%2520participants%2520were%2520diagnosed%2520with%2520at%2520least%2520one%2520CVD,%2520including%25206,912%2520cases%2520of%2520ischemic%2520stroke,%25201,664%2520cases%2520of%2520hemorrhagic%2520stroke,%25206,635%2520cases%2520of%2520myocardial%2520infarction,%252010,090%2520cases%2520of%2520heart%2520failure,%25201,872%2520cases%2520of%2520aortic%2520stenosis,%252013,167%2520cases%2520of%2520atrial%2520fibrillation,%2520and%25201,575%2520cases%2520of%2520abdominal%2520aortic%2520aneurysm.%2520The%2520associations%2520between%2520the%2520added%2520sugar%2520intake%2520and%2520the%2520studied%2520outcomes%2520were%2520generally%2520stronger%2520in%2520the%2520first%2520model%2520(adjusted%2520for%2520age,%2520sex,%2520and%2520total%2520energy%2520intake),%2520but%2520attenuated%2520in%2520the%2520second%2520model%2520(additionally%2520adjusted%2520for%2520lifestyle%2520factors),%2520and%2520further%2520attenuated%2520in%2520the%2520main%2520model%2520(additionally%2520adjusted%2520for%2520lifestyle%2520factors,%2520BMI,%2520and%2520dietary%2520factors)%2520(Supplementary%2520Tables%2520S3%25E2%2580%2593S9).%250AIndications%2520of%2520positive%2520linear%2520associations%2520(Ptrend%2520%253C%25200.01)%2520were%2520found%2520between%2520added%2520sugar%2520intake%2520and%2520risk%2520of%2520ischemic%2520stroke%2520and%2520abdominal%2520aortic%2520aneurysm%2520in%2520the%2520main%2520model.%2520For%2520abdominal%2520aortic%2520aneurysm,%2520a%252031%2525%2520(95%2525%2520CI:%25205%25E2%2580%259365%2525)%2520higher%2520risk%2520of%2520abdominal%2520aortic%2520aneurysm%2520was%2520found%2520for%2520added%2520sugar%2520intakes%2520of%2520%253E20E%2525,%2520and%2520for%2520ischemic%2520stroke,%2520a%25209%2525%2520(95%2525%2520CI:%25200%25E2%2580%259319%2525)%2520higher%2520risk%2520was%2520found%2520for%2520intakes%2520of%2520%253E15%25E2%2580%259320%2520E%2525,%2520compared%2520to%2520the%2520lowest%2520intake%2520category%2520of%2520%25E2%2589%25A4%25205%2520E%2525.%2520For%2520a%2520majority%2520of%2520the%2520outcomes,%2520however,%2520the%2520highest%2520risks%2520were%2520found%2520in%2520the%2520lowest%2520intake%2520category,%2520whereas%2520the%2520lowest%2520risks%2520were%2520found%2520for%2520low-%2520to%2520moderate%2520intakes.%2520Compared%2520to%2520the%2520lowest%2520intake%2520category%2520(%2520%25E2%2589%25A4%25205%2520E%2525),%2520added%2520sugar%2520intake%2520of%2520%253E5%25E2%2580%25937.5%2520E%2525%2520was%2520linked%2520with%2520statistically%2520significant%2520lower%2520risks%2520of%2520ischemic%2520stroke%2520%255B8%2525%2520(95%2525%2520CI:%25202-13%2525)%255D,%2520myocardial%2520infarction%2520%255B5%2525%2520(95%2525%2520CI:%25200%25E2%2580%259311%2525)%255D,%2520heart%2520failure%2520%255B9%2525%2520(95%2525%2520CI:%25205%25E2%2580%259313%2525)%255D,%2520aortic%2520stenosis%2520%255B9%2525%2520(95%2525%2520CI:%25200%25E2%2580%259318%2525)%255D,%2520and%2520atrial%2520fibrillation%2520%255B7%2525%2520(95%2525%2520CI:%25203%25E2%2580%259311%2525)%255D.%2520Furthermore,%2520compared%2520to%2520added%2520sugar%2520intakes%2520%25E2%2589%25A4%25205%2520E%2525,%2520lower%2520risks%2520of%2520heart%2520failure%2520and%2520atrial%2520fibrillation%2520were%2520found%2520for%2520intakes%2520of%2520%253E7.5%25E2%2580%259310%2520E%2525%2520%255B6%2525%2520(95%2525%2520CI:%25201%25E2%2580%259310%2525),%2520and%25204%2525%2520(95%2525%2520CI:%25200%25E2%2580%25938%2525),%2520respectively%255D,%2520as%2520well%2520as%2520of%2520heart%2520failure,%2520atrial%2520fibrillation,%2520and%2520aortic%2520stenosis%2520for%2520intakes%2520of%2520%253E10%25E2%2580%259315%2520E%2525%2520%255B5%2525%2520(95%2525%2520CI:%25200%25E2%2580%259310%2525),%25204%2525%2520(95%2525%2520CI:%25200%25E2%2580%25938%2525),%2520and%252017%2525%2520(95%2525%2520CI:%25207%25E2%2580%259326%2525),%2520respectively%255D.%2520No%2520associations%2520were%2520found%2520between%2520added%2520sugar%2520intake%2520and%2520hemorrhagic%2520stroke%2520risk%2520(Figure%25202,%2520Table%25203).%250A%250AFigure%25202%250AFigure%25202.%2520Restricted%2520cubic%2520splines%2520of%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520as%2520a%2520continuous%2520variable%2520and%2520risk%2520of%2520incident%2520ischemic%2520stroke%2520(A),%2520hemorrhagic%2520stroke%2520(B),%2520myocardial%2520infarction%2520(C),%2520heart%2520failure%2520(D),%2520aortic%2520stenosis%2520(E),%2520atrial%2520fibrillation%2520(F),%2520and%2520abdominal%2520aortic%2520aneurysm%2520(G)%2520using%2520a%2520Cox%2520proportional%2520hazards%2520regression%2520with%252010%2520E%2525%2520as%2520reference%2520value.%2520Adjusted%2520for%2520age,%2520sex,%2520total%2520energy%2520intake,%2520smoking%2520status,%2520educational%2520level,%2520alcohol%2520consumption,%2520walking/bicycling,%2520exercise,%2520BMI,%2520intake%2520of%2520processed%2520meat,%2520coffee,%2520saturated%2520fatty%2520acids,%2520and%2520fiber%2520intake.%2520The%2520solid%2520blue%2520line%2520represents%2520the%2520HR,%2520and%2520the%2520gray%2520area%2520represents%2520the%252095%2520CI.%2520HR,%2520Hazard%2520ratio;%2520CI,%2520Confidence%2520interval;%2520E%2525,%2520Percentage%2520of%2520energy%2520intake;%2520BMI,%2520Body%2520mass%2520index.%250A%250A%250ATable%25203%250ATable%25203.%2520Associations%2520between%2520added%2520sugar%2520intake%2520and%2520incidence%2520of%2520ischemic%2520stroke,%2520hemorrhagic%2520stroke,%2520myocardial%2520infarction,%2520heart%2520failure,%2520aortic%2520stenosis,%2520atrial%2520fibrillation,%2520and%2520abdominal%2520aortic%2520aneurysm%2520in%2520the%2520study%2520population.%250A%250A%250ASugar-sweetened%2520foods%2520and%2520beverages%2520and%2520CVDs%250AFor%2520sweetened%2520beverages,%2520positive%2520linear%2520associations%2520were%2520found%2520for%2520ischemic%2520stroke,%2520heart%2520failure,%2520atrial%2520fibrillation,%2520and%2520abdominal%2520aortic%2520aneurysm%2520(Ptrend%2520%253C%25200.001).%2520Intake%2520of%2520%253E8%2520servings%2520per%2520week%2520of%2520sweetened%2520beverages%2520was%2520associated%2520with%2520a%252019%2525%2520(95%2525%2520CI:%252011%25E2%2580%259327%2525)%2520higher%2520risk%2520of%2520ischemic%2520stroke,%2520an%252018%2525%2520(95%2525%2520CI:%252011%25E2%2580%259324%2525)%2520higher%2520risk%2520of%2520heart%2520failure,%2520an%252011%2525%2520(95%2525%2520CI:%25206%25E2%2580%259317%2525)%2520higher%2520risk%2520of%2520atrial%2520fibrillation,%2520and%2520a%252031%2525%2520(95%2525%2520CI:%252015%25E2%2580%259350%2525)%2520higher%2520risk%2520of%2520abdominal%2520aortic%2520aneurysm%2520(Supplementary%2520Tables%2520S3%25E2%2580%2593S9).%250AFor%2520treats,%2520negative%2520linear%2520associations%2520were%2520found%2520with%2520all%2520outcomes%2520(Ptrend%2520%253C%25200.01),%2520with%2520the%2520highest%2520risks%2520being%2520found%2520among%2520consumers%2520of%2520%25E2%2589%25A4%25202%2520servings/week%2520(Supplementary%2520Tables%2520S3%25E2%2580%2593S9).%250AFor%2520toppings,%2520negative%2520linear%2520associations%2520were%2520found%2520with%2520heart%2520failure,%2520and%2520aortic%2520stenosis,%2520while%2520a%2520positive%2520linear%2520association%2520was%2520found%2520with%2520abdominal%2520aortic%2520aneurysm%2520(Ptrend%2520%253C%25200.01).%2520Specifically,%2520~10%2525%2520lower%2520risks%2520of%2520heart%2520failure%2520were%2520found%2520for%2520all%2520intake%2520categories%2520compared%2520to%2520the%2520lowest%2520intake%2520category%2520(%2520%25E2%2589%25A4%25202%2520servings/week).%2520A%252034%2525%2520(95%2525%2520CI:%252018%25E2%2580%259351%2525)%2520higher%2520risk%2520of%2520abdominal%2520aortic%2520aneurysm%2520was%2520found%2520for%2520the%2520highest%2520intake%2520category%2520of%2520toppings%2520(%253E28%2520servings/week)%2520compared%2520to%2520the%2520lowest%2520intake%2520category.%2520For%2520aortic%2520stenosis,%252016%2525%2520(95%2525%2520CI:%25205%25E2%2580%259325%2525),%252020%2525%2520(95%2525%2520CI:%25209%25E2%2580%259329%2525),%2520and%252015%2525%2520(95%2525%2520CI:%25203%25E2%2580%259325%2525)%2520lower%2520risks%2520were%2520found%2520for%2520toppings%2520intakes%2520of%2520%253E7%25E2%2580%259314,%2520%253E14%25E2%2580%259328,%2520and%2520%253E28%2520servings/week,%2520respectively,%2520compared%2520to%2520the%2520lowest%2520intake%2520category%2520(Supplementary%2520Tables%2520S3%25E2%2580%2593S9).%250ASensitivity%2520analyses%250ANo%2520interactions%2520were%2520found%2520between%2520sex%2520and%2520added%2520sugar%2520intake%2520for%2520the%2520studied%2520outcomes%2520(P%2520%253E%25200.05).%2520Interactions%2520were%2520found%2520between%2520added%2520sugar%2520intake%2520and%2520BMI%2520for%2520atrial%2520fibrillation%2520and%2520heart%2520failure%2520(P%2520%253C%25200.05).%2520Higher%2520added%2520sugar%2520intake%2520was%2520associated%2520with%2520higher%2520risks%2520of%2520abdominal%2520aortic%2520aneurysm%2520and%2520ischemic%2520stroke%2520in%2520individuals%2520with%2520BMI%2520%253E25%2520kg/m2,%2520while%2520higher%2520added%2520sugar%2520intake%2520was%2520associated%2520with%2520a%2520higher%2520risk%2520of%2520heart%2520failure%2520in%2520individuals%2520with%2520BMI%252018.5%25E2%2580%259325%2520kg/m2%2520(Supplementary%2520Tables%2520S10,%2520S11,%2520Figure%25203).%250A%250AFigure%25203%250AFigure%25203.%2520Forest%2520plot%2520describing%2520the%2520HR%2520(95%2525%2520CI)%2520per%2520E%2525%2520increase%2520of%2520added%2520sugar%2520intake%2520for%2520incident%2520cardiovascular%2520disease%2520in%2520participants%2520stratified%2520by%2520BMI%252018.5%25E2%2580%259325%2520kg/m2%2520and%252025%2520kg/m2.%2520*Statistically%2520significant%2520association.%2520CI,%2520Confidence%2520interval;%2520HR,%2520Hazard%2520ratio.%250A%250A%250AThe%2520associations%2520for%2520sugar-sweetened%2520beverage%2520and%2520artificially%2520sweetened%2520beverage%2520intake%2520were%2520studied%2520separately%2520among%2520the%252042,327%2520participants%2520who%2520had%2520answered%2520the%25202009%2520dietary%2520assessment.%2520Among%2520these%2520participants,%252010,843%2520individuals%2520reported%2520consumption%2520of%2520at%2520least%25201%2520serving/week%2520of%2520sugar-sweetened%2520beverages,%2520and%25205,727%2520participants%2520reported%2520consumption%2520of%2520at%2520least%25201%2520serving/week%2520of%2520artificially%2520sweetened%2520beverages.%2520Positive%2520linear%2520associations%2520were%2520observed%2520between%2520intake%2520of%2520artificially%2520sweetened%2520beverages%2520and%2520risk%2520of%2520ischemic%2520stroke%2520(Ptrend%2520%253C%25200.01)%2520and%2520heart%2520failure%2520(Ptrend%2520%253C%25200.01)%2520(Supplementary%2520Table%2520S12),%2520while%2520intake%2520of%2520sugar-sweetened%2520beverages%2520was%2520not%2520associated%2520with%2520CVD%2520risk%2520(Supplementary%2520Table%2520S13).%250ATo%2520take%2520comorbidity%2520into%2520consideration,%2520all%2520participants%2520with%2520prior%2520incidence%2520of%2520the%2520other%2520studied%2520CVDs%2520during%2520the%2520follow-up%2520period%2520were%2520excluded%2520for%2520each%2520studied%2520outcome.%2520This%2520resulted%2520in%2520slightly%2520attenuated%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520most%2520of%2520the%2520studied%2520outcomes;%2520however,%2520the%2520tendencies%2520and%2520directions%2520of%2520the%2520previously%2520linear%2520associations%2520remained,%2520as%2520positive%2520linear%2520associations%2520were%2520observed%2520for%2520ischemic%2520stroke%2520(Ptrend%2520%253D%25200.05)%2520and%2520abdominal%2520aortic%2520aneurysm%2520(Ptrend%2520%253C%25200.01),%2520while%2520a%2520negative%2520linear%2520association%2520was%2520observed%2520between%2520added%2520sugar%2520intake%2520and%2520incident%2520aortic%2520stenosis%2520(Ptrend%2520%253D%25200.04)%2520(Supplementary%2520Table%2520S14).%250AThe%2520risk%2520estimates%2520did%2520not%2520differ%2520notably%2520when%2520testing%2520the%2520associations%2520for%2520added%2520sugar%2520and%2520sugar-sweetened%2520food%2520and%2520beverage%2520intake%2520with%2520energy%2520adjustments%2520using%2520the%2520nutrient%2520density%2520method%2520or%2520the%2520residual%2520method%2520for%2520added%2520sugar%2520intake,%2520nor%2520between%2520the%2520standard%2520multivariate%2520method,%2520nutrient%2520density%2520method,%2520or%2520residual%2520method%2520for%2520sugar-sweetened%2520foods%2520and%2520beverages%2520(Supplementary%2520Tables%2520S15%25E2%2580%2593S18).%250AWhen%2520studying%2520the%2520associations%2520between%2520added%2520sugar%2520and%2520CVD%2520incidence%2520using%2520the%25201997%2520dietary%2520data%2520only,%2520the%2520results%2520were%2520similar%2520to%2520the%2520main%2520results%2520but%2520with%2520lower%2520precision%2520(Supplementary%2520Table%2520S19).%2520Similarly,%2520excluding%2520cases%2520of%2520the%2520studied%2520outcomes%2520within%2520the%2520first%25203%2520years%2520of%2520the%2520follow-up%2520period%2520did%2520not%2520alter%2520the%2520results%2520(Supplementary%2520Table%2520S20).%250AWhen%2520only%2520including%2520the%2520participants%2520with%2520complete%2520data%2520for%2520sugar-sweetened%2520foods%2520and%2520beverages%2520and%2520categorical%2520covariates,%2520the%2520overall%2520results%2520remained%2520similar%2520to%2520the%2520main%2520analyses%2520(Supplementary%2520Tables%2520S21%25E2%2580%2593S24).%250ADiscussion%250AThe%2520findings%2520of%2520this%2520study%2520on%2520the%2520associations%2520between%2520added%2520sugar%2520and%2520CVD%2520risk%2520indicate%2520that%2520the%2520associations%2520vary%2520depending%2520on%2520the%2520disease%2520and%2520the%2520source%2520of%2520added%2520sugar,%2520demonstrating%2520the%2520importance%2520of%2520studying%2520them%2520separately.%2520There%2520were%2520statistically%2520significant%2520linear%2520associations%2520between%2520total%2520added%2520sugar%2520intake%2520and%2520ischemic%2520stroke%2520and%2520abdominal%2520aortic%2520aneurysm,%2520but%2520the%2520highest%2520risk%2520of%2520most%2520of%2520the%2520studied%2520outcomes%2520were%2520found%2520in%2520the%2520lowest%2520intake%2520category.%2520High%2520intake%2520of%2520sweetened%2520beverages%2520was%2520associated%2520with%2520higher%2520risk%2520for%2520most%2520of%2520the%2520studied%2520outcomes,%2520for%2520which%2520positive%2520linear%2520associations%2520were%2520found.%2520In%2520contrast,%2520a%2520low%2520intake%2520of%2520treats%2520was%2520associated%2520with%2520a%2520higher%2520risk%2520of%2520all%2520the%2520studied%2520outcomes.%2520Incorporating%2520the%2520time-updated%25202009%2520information%2520in%2520the%2520analyses%2520resulted%2520in%2520higher%2520precision%2520of%2520the%2520results.%250AVery%2520few%2520studies%2520have%2520investigated%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520incidence%2520of%2520specific%2520CVDs,%2520and%2520this%2520study%2520is,%2520to%2520the%2520best%2520of%2520our%2520knowledge,%2520the%2520first%2520one%2520to%2520investigate%2520the%2520associations%2520with%2520many%2520of%2520the%2520studied%2520outcomes%2520such%2520as%2520for%2520example%2520abdominal%2520aortic%2520aneurysm%2520and%2520atrial%2520fibrillation.%2520Results%2520from%2520the%2520Women's%2520Health%2520Initiative%2520did%2520not%2520show%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520incident%2520heart%2520failure%2520nor%2520stroke%2520(14).%2520In%2520the%2520Swedish%2520Malm%25C3%25B6%2520Diet%2520and%2520Cancer%2520Study,%2520the%2520associations%2520for%2520sugar%2520intake%2520also%2520varied%2520depending%2520on%2520CVD%2520disease%2520and%2520source%2520of%2520added%2520sugar%2520(13,%252021).%2520In%2520that%2520study,%2520U-shaped%2520associations%2520were%2520found%2520between%2520added%2520sugar%2520intake%2520and%2520overall%2520stroke%2520risk%2520(13).%2520In%2520a%2520study%2520of%2520UK%2520biobank%2520participants,%2520free%2520sugar%2520intake%2520was%2520linearly%2520associated%2520with%2520overall%2520stroke%2520risk%2520(15).%2520In%2520the%2520current%2520cohort%2520we%2520divided%2520stroke%2520into%2520subtypes%2520and%2520found%2520a%2520positive%2520linear%2520association%2520with%2520ischemic%2520stroke%2520(Ptrend%2520%253C%25200.01)%2520but%2520no%2520associations%2520with%2520hemorrhagic%2520stroke.%2520The%2520non-linear%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520atrial%2520fibrillation%2520and%2520aortic%2520stenosis%2520were%2520comparable%2520between%2520the%2520Malm%25C3%25B6%2520Diet%2520and%2520Cancer%2520Study%2520and%2520this%2520study,%2520with%2520the%2520highest%2520relative%2520risk%2520found%2520in%2520the%2520lowest%2520intake%2520category%2520for%2520both%2520outcomes.%250AAlthough%2520mechanisms%2520explaining%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520are%2520not%2520well-established,%2520several%2520biological%2520mechanisms%2520have%2520been%2520proposed.%2520One%2520hypothesis%2520is%2520based%2520on%2520the%2520distinct%2520metabolism%2520of%2520fructose,%2520a%2520component%2520of%2520the%2520common%2520added%2520sugar%2520sucrose.%2520Fructose%2520is%2520metabolized%2520in%2520the%2520liver%2520and%2520converted%2520to%2520glycerol-3-phosphate,%2520which%2520serves%2520as%2520a%2520backbone%2520for%2520triacylglycerol%2520synthesis,%2520leading%2520to%2520increased%2520triacylglycerol%2520synthesis%2520and%2520ultimately%2520increased%2520CVD%2520risk%2520(20,%252030).%2520It%2520is%2520important%2520to%2520highlight%2520that%2520the%2520notion%2520of%2520adverse%2520metabolic%2520effects%2520of%2520fructose%2520has%2520been%2520questioned,%2520as%2520many%2520studies%2520on%2520the%2520topic%2520refer%2520to%2520very%2520high%2520intakes%2520of%2520fructose%2520(%253E95th%2520percentile)%2520which%2520do%2520not%2520reflect%2520the%2520metabolic%2520effects%2520of%2520normal%2520dietary%2520intakes%2520(31,%252032).%2520The%2520EFSA%2520scientific%2520opinion%2520on%2520a%2520tolerable%2520upper%2520intake%2520level%2520for%2520dietary%2520sugars%2520does%2520however%2520state%2520that%2520evidence%2520from%2520prospective%2520cohort%2520studies%2520suggest%2520positive%2520and%2520causal%2520relationship%2520between%2520the%2520intake%2520of%2520fructose%2520and%2520risk%2520of%2520cardiovascular%2520diseases,%2520albeit%2520with%2520a%2520low%2520level%2520of%2520certainty%2520(6).%250ARelationships%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520factors%2520such%2520as%2520dyslipidaemia%2520(5,%25206),%2520hypertension%2520(6),%2520and%2520obesity,%2520have%2520been%2520shown%2520in%2520both%2520randomized%2520controlled%2520trials%2520and%2520observational%2520studies,%2520and%2520could%2520help%2520explain%2520the%2520associations%2520found%2520between%2520added%2520sugar%2520intake%2520and%2520some%2520of%2520the%2520studied%2520CVDs.%2520Although%2520the%2520mentioned%2520CVD%2520risk%2520factors%2520affect%2520all%2520of%2520the%2520studied%2520CVDs%2520to%2520some%2520extent,%2520one%2520explanation%2520for%2520the%2520findings%2520for%2520the%2520different%2520CVDs%2520may%2520be%2520that%2520the%2520risk%2520factors%2520affect%2520the%2520diseases%2520to%2520varying%2520degrees.%2520For%2520example,%2520aortic%2520stenosis%2520can%2520be%2520caused%2520by%2520congenital%2520heart%2520defects%2520and%2520hemorrhagic%2520stroke%2520can%2520be%2520caused%2520by%2520head%2520injuries,%2520whereas%2520ischemic%2520stroke%2520and%2520abdominal%2520aortic%2520aneurysm%2520might%2520be%2520more%2520dependent%2520on%2520atherosclerotic%2520processes.%2520This%2520could%2520result%2520in%2520the%2520potential%2520effect%2520of%2520dietary%2520factors%2520on%2520disease%2520incidence%2520being%2520smaller%2520and%2520more%2520difficult%2520to%2520discern%2520for%2520some%2520of%2520the%2520studied%2520outcomes.%2520This%2520would%2520however%2520not%2520explain%2520the%2520lack%2520of%2520associations%2520found%2520with%2520for%2520example%2520myocardial%2520infarction,%2520as%2520it%2520is%2520also%2520a%2520highly%2520atherosclerotic%2520disease.%2520Consequently,%2520more%2520research%2520is%2520needed%2520to%2520gain%2520deeper%2520understanding%2520of%2520the%2520possible%2520associations%2520and%2520mechanisms%2520of%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk.%250AThe%2520results%2520for%2520the%2520associations%2520between%2520added%2520sugar%2520and%2520some%2520CVDs%2520in%2520individuals%2520with%2520overweight%2520and%2520obesity%2520in%2520this%2520study%2520suggest%2520that%2520BMI%2520may%2520be%2520an%2520effect%2520modifier%2520of%2520the%2520associations,%2520which%2520could%2520explain%2520some%2520of%2520the%2520discrepancies%2520between%2520studies%2520as%2520the%2520rates%2520of%2520overweight%2520or%2520obesity%2520vary%2520in%2520different%2520populations.%2520The%2520role%2520of%2520BMI%2520as%2520a%2520potential%2520effect%2520modifier%2520of%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520consequently%2520warrants%2520further%2520investigation.%2520Further,%2520although%2520consumption%2520of%2520%253C%25205%2520E%2525%2520of%2520added%2520sugar%2520was%2520associated%2520with%2520a%2520higher%2520risk%2520of%2520several%2520CVDs,%2520it%2520is%2520important%2520to%2520highlight%2520that%2520there%2520are%2520no%2520well-established%2520biological%2520mechanistic%2520explanations%2520for%2520these%2520associations.%2520Findings%2520from%2520the%2520Australian%2520Health%2520Survey%25202011%25E2%2580%25932012%2520(weighted%2520n%2520%253D%25206,150)%2520did%2520however%2520indicate%2520that%2520added%2520sugar%2520intakes%2520below%25205%2520E%2525%2520were%2520associated%2520with%2520lower%2520micronutrient%2520intakes%2520(33),%2520and%2520it%2520is%2520also%2520possible%2520that%2520the%2520added%2520sugar%2520is%2520substituted%2520by%2520other%2520nutrients%2520such%2520as%2520for%2520example%2520saturated%2520fats.%2520Both%2520of%2520these%2520factors%2520could%2520contribute%2520to%2520adverse%2520cardiovascular%2520health.%2520On%2520the%2520other%2520hand,%2520results%2520from%2520two%2520Swedish%2520populations%2520(n%2520%253D%252012,238%2520and%2520n%2520%253D%25201,797)%2520indicated%2520an%2520inverse%2520association%2520between%2520added%2520sugar%2520intake%2520and%2520micronutrient%2520intake,%2520contradicting%2520the%2520micronutrient%2520dilution%2520theory%2520(34).%2520Finally,%2520methodological%2520limitations%2520such%2520as%2520residual%2520confounding%2520and%2520misreporting%2520could%2520affect%2520the%2520results%2520and%2520explain%2520some%2520of%2520the%2520findings.%2520The%2520overall%2520findings%2520based%2520on%2520CVD%2520health%2520do%2520not%2520support%2520lowering%2520the%2520recommendations%2520for%2520added%2520sugar%2520intake%2520to%2520below%25205%2520E%2525,%2520although%2520they%2520do%2520indicate%2520lower%2520risks%2520of%2520CVDs%2520among%2520consumers%2520of%2520%253E5%25E2%2580%25937.5%2520E%2525%2520than%2520among%2520consumers%2520of%252010%2520E%2525%2520of%2520added%2520sugar.%250AThe%2520clear%2520associations%2520between%2520overall%2520sweetened%2520beverage%2520intake%2520and%2520a%2520higher%2520risk%2520of%2520several%2520CVDs%2520(i.e.,%2520ischemic%2520stroke,%2520heart%2520failure,%2520atrial%2520fibrillation,%2520and%2520abdominal%2520aortic%2520aneurysm)%2520found%2520in%2520this%2520study%2520are%2520supported%2520by%2520previous%2520findings.%2520However,%2520the%2520findings%2520specifically%2520for%2520artificially%2520sweetened%2520beverages%2520and%2520sugar-sweetened%2520beverages%2520are%2520not%2520as%2520congruous%2520with%2520existing%2520literature%2520which%2520points%2520toward%2520them%2520being%2520associated%2520with%2520CVD%2520risk%2520as%2520well%2520as%2520risk%2520markers%2520for%2520CVD%2520(6,%252035%25E2%2580%259337).%2520In%2520this%2520study,%2520however,%2520higher%2520intake%2520of%2520artificially%2520sweetened%2520beverages%2520was%2520associated%2520with%2520increased%2520risks%2520of%2520ischemic%2520stroke%2520and%2520heart%2520failure,%2520while%2520no%2520associations%2520were%2520found%2520between%2520intake%2520of%2520sugar-sweetened%2520beverages%2520and%2520CVD%2520risk.%2520This%2520could%2520be%2520explained%2520by%2520a%2520relatively%2520low%2520frequency%2520of%2520sugar-%2520and%2520artificially%2520sweetened%2520beverage%2520consumption,%2520as%252010,843%2520(26%2525)%2520and%25205,727%2520(14%2525)%2520individuals,%2520respectively,%2520reported%2520consumption%2520of%2520at%2520least%25201%2520serving/week.%2520Only%25202,499%2520(6%2525)%2520individuals%2520consumed%2520%253E8%2520servings/week%2520of%2520sugar-sweetened%2520beverages%2520and%25201,660%2520(4%2525)%2520individuals%2520consumed%2520%253E8%2520servings/week%2520of%2520artificially%2520sweetened%2520beverages.%2520To%2520put%2520it%2520into%2520perspective,%2520a%2520review%2520article%2520reported%2520an%25208%2525%2520increased%2520CVD%2520risk%2520with%2520each%2520additional%2520consumed%2520serving%2520of%2520sugar-sweetened%2520beverages%2520per%2520day%2520(38),%2520thus%2520it%2520is%2520possible%2520that%2520there%2520were%2520too%2520few%2520sugar-%2520and%2520artificially%2520sweetened%2520beverage%2520consumers,%2520and%2520in%2520particular,%2520too%2520few%2520high-frequency%2520consumers,%2520to%2520detect%2520similar%2520associations.%2520It%2520should%2520also%2520be%2520mentioned,%2520however,%2520that%2520it%2520has%2520been%2520suggested%2520that%2520associations%2520found%2520with%2520artificially%2520sweetened%2520beverages%2520could%2520be%2520affected%2520by%2520reverse%2520causality%2520(36).%2520It%2520should%2520also%2520be%2520noted%2520that%2520while%2520some%2520literature%2520suggests%2520that%2520consumption%2520of%2520artificial%2520sweeteners%2520could%2520impact%2520cardiovascular%2520health%2520negatively%2520by%2520alteration%2520of%2520the%2520gut%2520microbiota,%2520the%2520collected%2520body%2520of%2520evidence%2520does%2520not%2520indicate%2520adverse%2520effects%2520of%2520artificially%2520sweetened%2520beverage%2520intake%2520on%2520CVD%2520risk%2520(39).%250AThe%2520findings%2520for%2520treats%2520are%2520consistent%2520with%2520previous%2520findings%2520in%2520the%2520Malm%25C3%25B6%2520Diet%2520and%2520Cancer%2520Study,%2520in%2520which%2520the%2520highest%2520risks%2520of%2520stroke,%2520coronary%2520events,%2520atrial%2520fibrillation,%2520and%2520aortic%2520stenosis%2520were%2520found%2520in%2520the%2520lowest%2520intake%2520category%2520(%2520%25E2%2589%25A4%25202%2520servings/week)%2520(13).%2520Similar%2520findings%2520were%2520reported%2520for%2520all-cause%2520mortality%2520in%2520the%2520Malm%25C3%25B6%2520Diet%2520and%2520Cancer%2520Study%2520and%2520the%2520Northern%2520Swedish%2520Health%2520and%2520Disease%2520Study,%2520where%2520inverse%2520associations%2520were%2520reported%2520with%2520intake%2520of%2520treats%2520(21).%2520The%2520findings%2520for%2520toppings%2520are%2520less%2520uniform,%2520as%2520the%2520results%2520from%2520this%2520study%2520indicated%2520positive%2520associations%2520between%2520intake%2520of%2520toppings%2520and%2520risk%2520of%2520heart%2520failure%2520and%2520aortic%2520stenosis,%2520and%2520negatively%2520associated%2520with%2520risk%2520of%2520abdominal%2520aortic%2520aneurysm,%2520while%2520no%2520associations%2520were%2520found%2520with%2520intake%2520of%2520toppings%2520and%2520CVD%2520risk%2520in%2520Malm%25C3%25B6%2520Diet%2520and%2520Cancer%2520Study%2520(13).%2520Given%2520that%2520this%2520study%2520has%2520more%2520than%2520twice%2520as%2520many%2520participants%2520as%2520the%2520Malm%25C3%25B6%2520Diet%2520and%2520Cancer%2520Study,%2520it%2520is%2520possible%2520that%2520the%2520discrepancy%2520could%2520be%2520due%2520to%2520a%2520higher%2520power%2520to%2520detect%2520associations.%250AThe%2520findings%2520of%2520this%2520study%2520indicate%2520that%2520not%2520all%2520sources%2520of%2520added%2520sugar%2520are%2520equally%2520harmful%2520to%2520health,%2520as%2520sugar-sweetened%2520beverages%2520are%2520the%2520primary%2520source%2520of%2520added%2520sugar%2520associated%2520with%2520increased%2520CVD%2520risk.%2520Possible%2520explanations%2520of%2520the%2520discrepancies%2520between%2520the%2520associations%2520for%2520sweetened%2520beverages%2520and%2520treats%2520and%2520toppings%2520include%2520liquid%2520calories%2520providing%2520lower%2520satiety%2520and%2520insufficient%2520compensatory%2520reduction%2520of%2520caloric%2520intake,%2520thus%2520promoting%2520overweight%2520and%2520obesity,%2520which%2520are%2520established%2520risk%2520factors%2520for%2520CVD%2520(40).%2520It%2520should%2520be%2520noted%2520that%2520there%2520are%2520currently%2520no%2520mechanistic%2520explanations%2520for%2520the%2520negative%2520linear%2520associations%2520found%2520for%2520treats.%2520One%2520aspect%2520to%2520take%2520into%2520consideration%2520is%2520however%2520that%2520there%2520is%2520a%2520social%2520tradition%2520of%2520%25E2%2580%259Cfika%25E2%2580%259D%2520in%2520Sweden,%2520where%2520people%2520get%2520together%2520with%2520friends,%2520relatives,%2520or%2520coworkers%2520for%2520coffee%2520and%2520pastries%2520(41).%2520Thus,%2520one%2520could%2520hypothesize%2520that%2520the%2520intake%2520of%2520treats%2520is%2520part%2520of%2520many%2520people's%2520everyday%2520lives%2520without%2520necessarily%2520being%2520related%2520with%2520overall%2520poor%2520dietary%2520or%2520lifestyle%2520patterns,%2520and%2520that%2520it%2520might%2520be%2520a%2520marker%2520of%2520social%2520life.%2520Consumption%2520of%2520sweetened%2520beverages,%2520one%2520the%2520other%2520hand,%2520has%2520been%2520linked%2520to%2520lower%2520overall%2520dietary%2520quality%2520(42).%250ADespite%2520adjusting%2520for%2520plausible%2520confounders,%2520we%2520cannot%2520rule%2520out%2520the%2520presence%2520of%2520confounders%2520due%2520to%2520the%2520observational%2520nature%2520of%2520this%2520study%2520and%2520the%2520complexity%2520of%2520diet%2520as%2520an%2520exposure.%2520The%2520confounders%2520are%2520also%2520likely%2520to%2520differ%2520between%2520the%2520outcomes.%2520In%2520this%2520study,%2520while%2520adjustments%2520were%2520made%2520for%2520processed%2520meat%2520consumption,%2520a%2520significant%2520contributor%2520to%2520sodium%2520intake%2520in%2520Sweden,%2520direct%2520sodium%2520intake%2520was%2520not%2520accounted%2520for.%2520The%2520FFQ%2520used%2520in%2520the%2520cohorts%2520did%2520not%2520account%2520for%2520salt%2520used%2520in%2520cooking%2520or%2520at%2520the%2520table,%2520and%2520therefore,%2520dietary%2520sodium%2520intake%2520could%2520not%2520be%2520estimated.%2520Moreover,%2520existing%2520literature%2520indicates%2520poor%2520agreement%2520between%2520sodium%2520intake%2520estimated%2520from%2520FFQs%2520and%2520urinary%2520sodium%2520excretion%2520(43),%2520highlighting%2520the%2520need%2520for%2520future%2520research%2520to%2520incorporate%2520more%2520accurate%2520measures,%2520such%2520as%2520urinary%2520sodium%2520excretion,%2520to%2520more%2520precisely%2520assess%2520the%2520impact%2520of%2520sodium%2520intake%2520as%2520a%2520potential%2520confounding%2520factor.%2520Further,%2520we%2520did%2520not%2520adjust%2520for%2520factors%2520accounting%2520for%2520social%2520networks,%2520which%2520is%2520something%2520that%2520should%2520be%2520further%2520explored%2520in%2520future%2520studies.%2520As%2520inverse%2520associations%2520have%2520been%2520found%2520between%2520intake%2520of%2520treats%2520and%2520CVD%2520incidence%2520in%2520these%2520cohorts%2520as%2520well%2520as%2520others%2520(21),%2520intake%2520of%2520treats%2520should%2520be%2520studied%2520closer%2520with%2520regards%2520to%2520biological%2520mechanisms%2520as%2520well%2520as%2520possible%2520correlations%2520with%2520other%2520factors%2520that%2520could%2520impact%2520the%2520observed%2520associations.%2520Other%2520limitations%2520of%2520this%2520study%2520include%2520the%2520self-reported%2520dietary%2520information,%2520which%2520may%2520introduce%2520some%2520misreporting%2520and,%2520as%2520a%2520result,%2520misclassification%2520of%2520exposure.%2520Although%2520we%2520excluded%2520individuals%2520deemed%2520to%2520have%2520implausible%2520energy%2520intakes,%2520some%2520misclassification%2520of%2520exposure%2520may%2520remain.%2520Additionally,%2520approximately%252039%2525%2520of%2520the%2520participants%2520did%2520not%2520complete%2520the%25202009%2520assessment,%2520meaning%2520that%2520information%2520on%2520diet%2520and%2520covariates%2520was%2520only%2520available%2520during%2520baseline%2520for%2520those%2520participants.%250AIn%2520comparison%2520to%2520the%2520national%2520mean%2520added%2520sugar%2520intake%2520of%25209.6%2520E%2525%2520in%2520Sweden%2520in%25202010%25E2%2580%25932011%2520(8),%2520the%2520mean%2520added%2520sugar%2520intakes%2520in%2520the%2520study%2520population%2520were%2520lower,%2520estimated%2520to%2520be%25209.0%2520E%2525%2520in%25201997%2520and%25206.7%2520E%2525%2520in%25202009.%2520In%2520this%2520study%2520population,%2520the%2520intakes%2520of%2520sugar-sweetened%2520foods%2520and%2520beverages%2520were%2520also%2520lower%2520in%25202009%2520than%2520in%25201997,%2520despite%2520the%2520national%2520intake%2520levels%2520of%2520sweetened%2520beverages%2520and%2520treats%2520increasing%2520throughout%2520the%2520same%2520period%2520(44).%2520Aside%2520from%2520an%2520actual%2520difference%2520in%2520sugar%2520intake%2520between%25201997%2520and%25202009%2520in%2520SMC%2520and%2520COSM,%2520one%2520possible%2520explanation%2520for%2520this%2520difference%2520is%2520that%2520the%2520general%2520perception%2520of%2520the%2520health%2520effects%2520of%2520added%2520sugar%2520differed%2520during%2520those%2520time%2520periods,%2520and%2520thus%2520it%2520could%2520be%2520theorized%2520that%2520misreporting%2520of%2520added%2520sugar%2520was%2520more%2520prevalent%2520in%25202009%2520than%2520in%25201997.%2520Despite%2520this,%2520the%2520precision%2520of%2520the%2520results%2520was%2520higher%2520when%2520incorporating%2520the%2520updated%2520information%2520from%25202009.%250AStrengths%2520of%2520this%2520study%2520include%2520the%2520large%2520study%2520population%2520of%252069,705%2520individuals%2520as%2520well%2520as%2520the%2520repeated%2520assessments%2520for%2520the%2520majority%2520of%2520the%2520participants,%2520which%2520allowed%2520us%2520to%2520gain%2520insights%2520into%2520the%2520participants'%2520diets%2520at%2520two%2520separate%2520time-points,%2520leading%2520to%2520higher%2520precision%2520and%2520likely%2520reducing%2520misclassification%2520of%2520exposure,%2520though%2520this%2520cannot%2520be%2520completely%2520ruled%2520out.%2520Finally,%2520because%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520different%2520CVD%2520outcomes%2520can%2520vary,%2520this%2520study%2520investigated%2520the%2520risk%2520of%2520the%2520CVDs%2520separately.%2520We%2520also%2520studied%2520added%2520sugar%2520intake%2520as%2520a%2520whole%2520and%2520in%2520groups%2520of%2520sugar-sweetened%2520foods%2520and%2520beverages,%2520providing%2520higher%2520granularity%2520and%2520further%2520insights%2520into%2520how%2520different%2520forms%2520of%2520added%2520sugar%2520intake%2520associate%2520with%2520CVD%2520risk.%2520Due%2520to%2520the%2520large%2520number%2520of%2520statistical%2520tests%2520performed%2520in%2520this%2520study,%2520there%2520is%2520a%2520risk%2520of%2520chance%2520findings.%2520The%2520findings%2520of%2520this%2520study%2520could%2520help%2520inform%2520future%2520dietary%2520guidelines%2520and%2520recommendations%2520which%2520could%2520guide%2520policies%2520to%2520reduce%2520CVD%2520incidence%2520and%2520ultimately%2520improve%2520public%2520health.%250AThe%2520results%2520of%2520this%2520study%2520are%2520consistent%2520with%2520previous%2520findings%2520in%2520another%2520Swedish%2520middle-aged%2520population%2520(13),%2520but%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520cannot%2520necessarily%2520be%2520generalized%2520to%2520other%2520populations%2520as%2520the%2520consumption%2520patterns%2520of%2520added%2520sugar%2520and%2520sugar-sweetened%2520foods%2520and%2520beverages%2520may%2520vary%2520across%2520countries%2520and%2520age%2520groups.%2520More%2520research%2520is%2520needed%2520to%2520discern%2520whether%2520the%2520observed%2520associations,%2520and%2520the%2520findings%2520for%2520treats%2520in%2520particular,%2520can%2520be%2520replicated%2520in%2520other%2520populations,%2520and%2520future%2520research%2520should%2520be%2520conducted%2520to%2520explore%2520potential%2520mechanisms%2520and%2520associations%2520with%2520intermediary%2520risk%2520factors.%2520To%2520acquire%2520a%2520better%2520understanding%2520of%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk,%2520other%2520methods%2520such%2520as%2520using%2520objective%2520biomarkers%2520or%2520Mendelian%2520randomizations%2520could%2520be%2520used%2520to%2520investigate%2520any%2520causal%2520links%2520between%2520added%2520sugar%2520intake%2520and%2520CVD%2520risk%2520in%2520observational%2520studies.%250AConclusion%250AAccording%2520to%2520the%2520findings%2520of%2520this%2520study,%2520the%2520associations%2520between%2520added%2520sugar%2520intake%2520and%2520CVDs%2520vary%2520substantially%2520depending%2520on%2520the%2520disease%2520and%2520source%2520of%2520added%2520sugar.%2520Finally,%2520the%2520findings%2520of%2520this%2520study%2520emphasize%2520the%2520adverse%2520health%2520effects%2520associated%2520with%2520sweetened%2520beverage%2520consumption%2520and%2520indicate%2520higher%2520CVD%2520risks%2520among%2520individuals%2520with%2520low%2520intakes%2520of%2520treats.%250AData%2520availability%2520statement%250AThe%2520data%2520is%2520accessed%2520through%2520SIMPLER%2520(Swedish%2520Infrastructure%2520for%2520Medical%2520Population-based%2520Life-course%2520and%2520Environmental%2520Research)%2520and%2520since%2520it%2520is%2520an%2520individual-based%2520database%2520and%2520biobank,%2520ethical%2520approval%2520is%2520needed%2520to%2520get%2520access%2520to%2520the%2520data.%2520Consequently,%2520for%2520ethical%2520reasons,%2520the%2520data%2520can't%2520be%2520openly%2520accessed%2520and%2520any%2520requests%2520to%2520access%2520these%2520datasets%2520should%2520be%2520directed%2520to%2520https://www.simpler4health.se/w/sh/en/researchers/data-access.%250AEthics%2520statement%250AThe%2520studies%2520involving%2520humans%2520were%2520approved%2520by%2520the%2520Swedish%2520Ethical%2520Review%2520Authority.%2520The%2520studies%2520were%2520conducted%2520in%2520accordance%2520with%2520the%2520local%2520legislation%2520and%2520institutional%2520requirements.%2520Written%2520informed%2520consent%2520for%2520participation%2520was%2520not%2520required%2520from%2520the%2520participants%2520or%2520the%2520participants'%2520legal%2520guardians/next%2520of%2520kin%2520in%2520accordance%2520with%2520the%2520national%2520legislation%2520and%2520institutional%2520requirements.%250AAuthor%2520contributions%250ASJ:%2520Writing%2520%25E2%2580%2593%2520original%2520draft,%2520Writing%2520%25E2%2580%2593%2520review%2520%2526%2520editing.%2520EG-P:%2520Writing%2520%25E2%2580%2593%2520review%2520%2526%2520editing.%2520SR:%2520Writing%2520%25E2%2580%2593%2520review%2520%2526%2520editing.%2520SB:%2520Writing%2520%25E2%2580%2593%2520review%2520%2526%2520editing.%2520YB:%2520Writing%2520%25E2%2580%2593%2520review%2520%2526%2520editing,%2520Methodology,%2520Supervision.%2520ES:%2520Conceptualization,%2520Funding%2520acquisition,%2520Supervision,%2520Writing%2520%25E2%2580%2593%2520review%2520%2526%2520editing.%250AFunding%250AThe%2520author(s)%2520declare%2520financial%2520support%2520was%2520received%2520for%2520the%2520research,%2520authorship,%2520and/or%2520publication%2520of%2520this%2520article.%2520This%2520research%2520was%2520funded%2520by%2520the%2520Swedish%2520Research%2520Council%2520(2016-01501,%25202020-01412),%2520the%2520Heart%2520and%2520Lung%2520Foundation%2520(2016-0267,%25202019-0555),%2520and%2520the%2520Albert%2520P%25C3%25A5hlsson%2520Foundation.%2520We%2520acknowledge%2520SIMPLER%2520for%2520provisioning%2520of%2520data%2520and%2520resources%2520used%2520for%2520this%2520project.%2520SIMPLER%2520receives%2520funding%2520through%2520the%2520Swedish%2520Research%2520Council%2520under%2520grant%2520no.%25202017-00644,%2520as%2520well%2520as%2520Swedish%2520Research%2520Council%2520grant%2520no.%25202017-06100%2520and%2520Stiftelsen%2520Olle%2520Engkvist%2520Byggm%25C3%25A4stare.%2520The%2520computations%2520were%2520performed%2520on%2520resources%2520provided%2520by%2520SNIC-SENS%2520through%2520the%2520Uppsala%2520Multidisciplinary%2520Center%2520for%2520Advanced%2520Computational%2520Science%2520(UPPMAX)%2520under%2520Project%2520SIMP2020012.%250AAcknowledgments%250AThe%2520authors%2520wish%2520to%2520acknowledge%2520the%2520contributions%2520of%2520the%2520participants%2520and%2520research%2520staff%2520of%2520the%2520SIMPLER%2520cohorts.%250AConflict%2520of%2520interest%250AThe%2520authors%2520declare%2520that%2520the%2520research%2520was%2520conducted%2520in%2520the%2520absence%2520of%2520any%2520commercial%2520or%2520financial%2520relationships%2520that%2520could%2520be%2520construed%2520as%2520a%2520potential%2520conflict%2520of%2520interest.%250APublisher's%2520note%250AAll%2520claims%2520expressed%2520in%2520this%2520article%2520are%2520solely%2520those%2520of%2520the%2520authors%2520and%2520do%2520not%2520necessarily%2520represent%2520those%2520of%2520their%2520affiliated%2520organizations,%2520or%2520those%2520of%2520the%2520publisher,%2520the%2520editors%2520and%2520the%2520reviewers.%2520Any%2520product%2520that%2520may%2520be%2520evaluated%2520in%2520this%2520article,%2520or%2520claim%2520that%2520may%2520be%2520made%2520by%2520its%2520manufacturer,%2520is%2520not%2520guaranteed%2520or%2520endorsed%2520by%2520the%2520publisher.%250ASupplementary%2520material%250AThe%2520Supplementary%2520Material%2520for%2520this%2520article%2520can%2520be%2520found%2520online%2520at:%2520https://www.frontiersin.org/articles/10.3389/fpubh.2024.1452085/full%2523supplementary-material%250AReferences%250A1.%2520Roth%2520GA,%2520Mensah%2520GA,%2520Johnson%2520CO,%2520Addolorato%2520G,%2520Ammirati%2520E,%2520Baddour%2520LM,%2520et%2520al.%2520Global%2520burden%2520of%2520cardiovascular%2520diseases%2520and%2520risk%2520factors,%25201990-2019:%2520update%2520from%2520the%2520GBD%25202019%2520study.%2520J%2520Am%2520Coll%2520Cardiol.%2520(2020)%252076:2982%25E2%2580%25933021.%2520doi:%252010.1016/j.jacc.2020.11.010%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A2.%2520Wilkins%2520E,%2520Wilson%2520L,%2520Wickramasinghe%2520K,%2520Bhatnagar%2520P,%2520Leal%2520J,%2520Luengo-Fernandez%2520R,%2520et%2520al.%2520European%2520cardiovascular%2520disease%2520statistics%25202017.%2520Technical%2520report%2520University%2520of%2520Oxford.%2520(2017).%250AGoogle%2520Scholar%250A3.%2520Khan%2520TA,%2520Tayyiba%2520M,%2520Agarwal%2520A,%2520Mejia%2520SB,%2520de%2520Souza%2520RJ,%2520Wolever%2520TMS,%2520et%2520al.%2520Relation%2520of%2520total%2520sugars,%2520sucrose,%2520fructose,%2520and%2520added%2520sugars%2520with%2520the%2520risk%2520of%2520cardiovascular%2520disease:%2520a%2520systematic%2520review%2520and%2520dose-response%2520meta-analysis%2520of%2520prospective%2520cohort%2520studies.%2520Mayo%2520Clin%2520Proc.%2520(2019)%252094:2399%25E2%2580%2593414.%2520doi:%252010.1016/j.mayocp.2019.05.034%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A4.%2520Keller%2520A,%2520Heitmann%2520BL,%2520Olsen%2520N.%2520Sugar-sweetened%2520beverages,%2520vascular%2520risk%2520factors%2520and%2520events:%2520a%2520systematic%2520literature%2520review.%2520Public%2520Health%2520Nutr.%2520(2015)%252018:1145%25E2%2580%259354.%2520doi:%252010.1017/S1368980014002122%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A5.%2520Bergwall%2520S,%2520Johansson%2520A,%2520Sonestedt%2520E,%2520Acosta%2520S.%2520High%2520versus%2520low-added%2520sugar%2520consumption%2520for%2520the%2520primary%2520prevention%2520of%2520cardiovascular%2520disease.%2520Cochrane%2520Database%2520Syst%2520Rev.%2520(2022)%25201:Cd013320.%2520doi:%252010.1002/14651858.CD013320.pub2%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A6.%2520EFSA%2520EFSA%2520Panel%2520on%2520Nutrition%2520NF,%2520Allergens%2520F,%2520Turck%2520D,%2520Bohn%2520T,%2520Castenmiller%2520J,%2520de%2520Henauw%2520S,%2520et%2520al.%2520Tolerable%2520upper%2520intake%2520level%2520for%2520dietary%2520sugars.%2520EFSA%2520J.%2520(2022)%252020:e07074.%2520doi:%252010.2903/j.efsa.2022.7074%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A7.%2520Yan%2520RR,%2520Chan%2520CB,%2520Louie%2520JCY.%2520Current%2520WHO%2520recommendation%2520to%2520reduce%2520free%2520sugar%2520intake%2520from%2520all%2520sources%2520to%2520below%252010%2525%2520of%2520daily%2520energy%2520intake%2520for%2520supporting%2520overall%2520health%2520is%2520not%2520well%2520supported%2520by%2520available%2520evidence.%2520Am%2520J%2520Clin%2520Nutr.%2520(2022)%2520116:15%25E2%2580%259339.%2520doi:%252010.1093/ajcn/nqac084%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A8.%2520Amcoff%2520E,%2520Edberg%2520A,%2520Enghardt%2520Barbieri%2520H,%2520Lindroos%2520A,%2520N%25C3%25A4ls%25C3%25A9n%2520C,%2520Warensj%25C3%25B6%2520Lemming%2520E.%2520Riksmaten%2520vuxna%25202010-11:%2520Livsmedels-%2520och%2520n%25C3%25A4ringsintag%2520bland%2520vuxna%2520i%2520Sverige.%2520Uppsala.%2520(2012).%250AGoogle%2520Scholar%250A9.%2520Ricciuto%2520L,%2520Fulgoni%2520VL,%2520Gaine%2520PC,%2520Scott%2520MO,%2520DiFrancesco%2520L.%2520Sources%2520of%2520added%2520sugars%2520intake%2520among%2520the%2520U.S.%2520population:%2520analysis%2520by%2520selected%2520sociodemographic%2520factors%2520using%2520the%2520national%2520health%2520and%2520nutrition%2520examination%2520survey%25202011%25E2%2580%259318.%2520Front%2520Nutr.%2520(2021)%25208:687643.%2520doi:%252010.3389/fnut.2021.687643%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A10.%2520Blomhoff%2520R,%2520Andersen%2520R,%2520Arnesen%2520EK,%2520Christensen%2520JJ,%2520Eneroth%2520H,%2520Erkkola%2520M,%2520et%2520al.%2520Nordic%2520Nutrition%2520Recommendations%25202023:%2520Integrating%2520Environmental%2520Aspects.%2520Copenhagen:%2520Nordisk%2520Ministerr%25C3%25A5d%2520(2023).%2520doi:%252010.6027/nord2023-003%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A11.%2520US%2520Department%2520of%2520Agriculture%2520and%2520US%2520Department%2520of%2520Health%2520and%2520Human%2520Services.%2520Dietary%2520Guidelines%2520for%2520Americans,%25202020%25E2%2580%25932025.%25209th%2520ed.%2520Washington,%2520DC:%2520US%2520Government%2520Publishing%2520Office%2520(2020).%250AGoogle%2520Scholar%250A12.%2520World%2520Health%2520Organization.%2520Guideline:%2520Sugars%2520Intake%2520for%2520Adults%2520and%2520Children.%2520Geneva:%2520World%2520Health%2520Organization;%25202015.%250AGoogle%2520Scholar%250A13.%2520Janzi%2520S,%2520Ramne%2520S,%2520Gonzalez-Padilla%2520E,%2520Johnson%2520L,%2520Sonestedt%2520E.%2520Associations%2520between%2520added%2520sugar%2520intake%2520and%2520risk%2520of%2520four%2520different%2520cardiovascular%2520diseases%2520in%2520a%2520swedish%2520population-based%2520prospective%2520cohort%2520study.%2520Front%2520Nutr.%2520(2020)%25207:603653.%2520doi:%252010.3389/fnut.2020.603653%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A14.%2520Yang%2520B,%2520Glenn%2520AJ,%2520Liu%2520Q,%2520Madsen%2520T,%2520Allison%2520MA,%2520Shikany%2520JM,%2520et%2520al.%2520Added%2520sugar,%2520sugar-sweetened%2520beverages,%2520and%2520artificially%2520sweetened%2520beverages%2520and%2520risk%2520of%2520cardiovascular%2520disease:%2520findings%2520from%2520the%2520women's%2520health%2520initiative%2520and%2520a%2520network%2520meta-analysis%2520of%2520prospective%2520studies.%2520Nutrients.%2520(2022)%252014:4226.%2520doi:%252010.3390/nu14204226%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A15.%2520Kelly%2520RK,%2520Tong%2520TYN,%2520Watling%2520CZ,%2520Reynolds%2520A,%2520Piernas%2520C,%2520Schmidt%2520JA,%2520et%2520al.%2520Associations%2520between%2520types%2520and%2520sources%2520of%2520dietary%2520carbohydrates%2520and%2520cardiovascular%2520disease%2520risk:%2520a%2520prospective%2520cohort%2520study%2520of%2520UK%2520Biobank%2520participants.%2520BMC%2520Med.%2520(2023)%252021:34.%2520doi:%252010.1186/s12916-022-02712-7%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A16.%2520Rippe%2520JM,%2520Angelopoulos%2520TJ.%2520Sugars,%2520obesity,%2520and%2520cardiovascular%2520disease:%2520results%2520from%2520recent%2520randomized%2520control%2520trials.%2520Eur%2520J%2520Nutr.%2520(2016)%252055:45%25E2%2580%259353.%2520doi:%252010.1007/s00394-016-1257-2%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A17.%2520Harris%2520H,%2520H%25C3%25A5kansson%2520N,%2520Olofsson%2520C,%2520Julin%2520B,%2520%25C3%2585kesson%2520A,%2520Wolk%2520A.%2520The%2520Swedish%2520mammography%2520cohort%2520and%2520the%2520cohort%2520of%2520Swedish%2520men:%2520Study%2520design%2520and%2520characteristics%2520of%25202%2520population-based%2520longitudinal%2520cohorts.%2520OA%2520Epidemiol.%2520(2013)%25201:16.%2520doi:%252010.13172/2053-079X-1-2-943%250ACrossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A18.%2520Bergstr%25C3%25B6m%2520L,%2520Kylberg%2520E,%2520Hagman%2520U,%2520Erikson%2520H,%2520Bruce%2520%25C3%2585.%2520The%2520food%2520composition%2520database%2520KOST:%2520the%2520National%2520Administration's%2520information%2520system%2520for%2520nutritive%2520values%2520of%2520food.%2520V%25C3%25A5r%2520f%25C3%25B6da.%2520(1991)%252043:439%25E2%2580%259347.%250AGoogle%2520Scholar%250A19.%2520Messerer%2520M,%2520Johansson%2520SE,%2520Wolk%2520A.%2520The%2520validity%2520of%2520questionnaire-based%2520micronutrient%2520intake%2520estimates%2520is%2520increased%2520by%2520including%2520dietary%2520supplement%2520use%2520in%2520Swedish%2520men.%2520J%2520Nutr.%2520(2004)%2520134:1800%25E2%2580%25935.%2520doi:%252010.1093/jn/134.7.1800%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A20.%2520Malik%2520VS,%2520Hu%2520FB.%2520Fructose%2520and%2520cardiometabolic%2520health:%2520what%2520the%2520evidence%2520from%2520sugar-sweetened%2520beverages%2520tells%2520us.%2520J%2520Am%2520Coll%2520Cardiol.%2520(2015)%252066:1615%25E2%2580%259324.%2520doi:%252010.1016/j.jacc.2015.08.025%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A21.%2520Ramne%2520S,%2520Alves%2520Dias%2520J,%2520Gonzalez-Padilla%2520E,%2520Olsson%2520K,%2520Lindahl%2520B,%2520Engstrom%2520G,%2520et%2520al.%2520Association%2520between%2520added%2520sugar%2520intake%2520and%2520mortality%2520is%2520nonlinear%2520and%2520dependent%2520on%2520sugar%2520source%2520in%25202%2520Swedish%2520population-based%2520prospective%2520cohorts.%2520Am%2520J%2520Clin%2520Nutr.%2520(2019)%2520109:411%25E2%2580%259323.%2520doi:%252010.1093/ajcn/nqy268%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A22.%2520Harrell%2520FE.%2520Regression%2520Modeling%2520Strategies:%2520With%2520Applications%2520to%2520Linear%2520Models,%2520Logistic%2520Regression,%2520and%2520Survival%2520Analysis.%2520New%2520York:%2520Springer%2520(2001).%2520doi:%252010.1007/978-1-4757-3462-1%250ACrossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A23.%2520Ludvigsson%2520JF,%2520Andersson%2520E,%2520Ekbom%2520A,%2520Feychting%2520M,%2520Kim%2520JL,%2520Reuterwall%2520C,%2520et%2520al.%2520External%2520review%2520and%2520validation%2520of%2520the%2520Swedish%2520national%2520inpatient%2520register.%2520BMC%2520Public%2520Health.%2520(2011)%252011:450.%2520doi:%252010.1186/1471-2458-11-450%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A24.%2520Eshak%2520ES,%2520Iso%2520H,%2520Kokubo%2520Y,%2520Saito%2520I,%2520Yamagishi%2520K,%2520Inoue%2520M,%2520et%2520al.%2520Soft%2520drink%2520intake%2520in%2520relation%2520to%2520incident%2520ischemic%2520heart%2520disease,%2520stroke,%2520and%2520stroke%2520subtypes%2520in%2520Japanese%2520men%2520and%2520women:%2520the%2520Japan%2520Public%2520Health%2520Centre-based%2520study%2520cohort%2520I.%2520Am%2520J%2520Clin%2520Nutr.%2520(2012)%252096:1390%25E2%2580%25937.%2520doi:%252010.3945/ajcn.112.037903%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A25.%2520Therneau%2520T.%2520A%2520Package%2520for%2520Survival%2520Analysis%2520in%2520R.%2520R%2520package%2520version%252034-0%2520ed.%2520(2022).%250AGoogle%2520Scholar%250A26.%2520Harrell%2520FE.%2520rms:%2520Regression%2520Modeling%2520Strategies.%2520R%2520package%2520version%252062-0%2520ed.%2520(2021).%2520doi:%252010.32614/CRAN.package.rmsb%250ACrossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A27.%2520Metra%2520M,%2520Zac%25C3%25A0%2520V,%2520Parati%2520G,%2520Agostoni%2520P,%2520Bonadies%2520M,%2520Ciccone%2520M,%2520et%2520al.%2520Cardiovascular%2520and%2520noncardiovascular%2520comorbidities%2520in%2520patients%2520with%2520chronic%2520heart%2520failure.%2520J%2520Cardiovasc%2520Med%2520(Hagerstown).%2520(2011)%252012:76%25E2%2580%259384.%2520doi:%252010.2459/JCM.0b013e32834058d1%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A28.%2520Kendir%2520C,%2520van%2520den%2520Akker%2520M,%2520Vos%2520R,%2520Metsemakers%2520J.%2520Cardiovascular%2520disease%2520patients%2520have%2520increased%2520risk%2520for%2520comorbidity:%2520a%2520cross-sectional%2520study%2520in%2520the%2520Netherlands.%2520Eur%2520J%2520Gen%2520Pract.%2520(2018)%252024:45%25E2%2580%259350.%2520doi:%252010.1080/13814788.2017.1398318%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A29.%2520Willett%2520WC,%2520Howe%2520GR,%2520Kushi%2520LH.%2520Adjustment%2520for%2520total%2520energy%2520intake%2520in%2520epidemiologic%2520studies.%2520Am%2520J%2520Clin%2520Nutr.%2520(1997)%252065:1220S%25E2%2588%25928S.%2520doi:%252010.1093/ajcn/65.4.1220S%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A30.%2520Fried%2520SK,%2520Rao%2520SP.%2520Sugars,%2520hypertriglyceridemia,%2520and%2520cardiovascular%2520disease.%2520Am%2520J%2520Clin%2520Nutr.%2520(2003)%252078:873s%25E2%2588%259280s.%2520doi:%252010.1093/ajcn/78.4.873S%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A31.%2520Dolan%2520LC,%2520Potter%2520SM,%2520Burdock%2520GA.%2520Evidence-based%2520review%2520on%2520the%2520effect%2520of%2520normal%2520dietary%2520consumption%2520of%2520fructose%2520on%2520blood%2520lipids%2520and%2520body%2520weight%2520of%2520overweight%2520and%2520obese%2520individuals.%2520Crit%2520Rev%2520Food%2520Sci%2520Nutr.%2520(2010)%252050:889%25E2%2580%2593918.%2520doi:%252010.1080/10408398.2010.512990%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A32.%2520Khan%2520TA,%2520Sievenpiper%2520JL.%2520Controversies%2520about%2520sugars:%2520results%2520from%2520systematic%2520reviews%2520and%2520meta-analyses%2520on%2520obesity,%2520cardiometabolic%2520disease%2520and%2520diabetes.%2520Eur%2520J%2520Nutr.%2520(2016)%252055:25%25E2%2580%259343.%2520doi:%252010.1007/s00394-016-1345-3%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A33.%2520Mok%2520A,%2520Ahmad%2520R,%2520Rangan%2520A,%2520Louie%2520JCY.%2520Intake%2520of%2520free%2520sugars%2520and%2520micronutrient%2520dilution%2520in%2520Australian%2520adults.%2520Am%2520J%2520Clin%2520Nutr.%2520(2018)%2520107:94%25E2%2580%2593104.%2520doi:%252010.1093/ajcn/nqx008%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A34.%2520Gonz%25C3%25A1lez-Padilla%2520E,%2520A.%2520Dias%2520D,%2520Ramne%2520S,%2520Olsson%2520K,%2520N%25C3%25A4ls%25C3%25A9n%2520C,%2520Sonestedt%2520E.%2520Association%2520between%2520added%2520sugar%2520intake%2520and%2520micronutrient%2520dilution:%2520a%2520cross-sectional%2520study%2520in%2520two%2520adult%2520Swedish%2520populations.%2520Nutr%2520Metab%2520(Lond).%2520(2020)%252017:15.%2520doi:%252010.1186/s12986-020-0428-6%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A35.%2520Jayalath%2520VH,%2520de%2520Souza%2520RJ,%2520Ha%2520V,%2520Mirrahimi%2520A,%2520Blanco-Mejia%2520S,%2520Di%2520Buono%2520M,%2520et%2520al.%2520Sugar-sweetened%2520beverage%2520consumption%2520and%2520incident%2520hypertension:%2520a%2520systematic%2520review%2520and%2520meta-analysis%2520of%2520prospective%2520cohorts.%2520Am%2520J%2520Clin%2520Nutr.%2520(2015)%2520102:914%25E2%2580%259321.%2520doi:%252010.3945/ajcn.115.107243%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A36.%2520Malik%2520VS,%2520Hu%2520FB.%2520The%2520role%2520of%2520sugar-sweetened%2520beverages%2520in%2520the%2520global%2520epidemics%2520of%2520obesity%2520and%2520chronic%2520diseases.%2520Nat%2520Rev%2520Endocrinol.%2520(2022)%252018:205%25E2%2580%259318.%2520doi:%252010.1038/s41574-021-00627-6%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A37.%2520Meng%2520Y,%2520Li%2520S,%2520Khan%2520J,%2520Dai%2520Z,%2520Li%2520C,%2520Hu%2520X,%2520et%2520al.%2520Sugar-%2520and%2520artificially%2520sweetened%2520beverages%2520consumption%2520linked%2520to%2520type%25202%2520diabetes,%2520cardiovascular%2520diseases,%2520and%2520all-cause%2520mortality:%2520a%2520systematic%2520review%2520and%2520dose-response%2520meta-analysis%2520of%2520prospective%2520cohort%2520studies.%2520Nutrients.%2520(2021)%252013:2336.%2520doi:%252010.3390/nu13082636%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A38.%2520Huang%2520Y,%2520Chen%2520Z,%2520Chen%2520B,%2520Li%2520J,%2520Yuan%2520X,%2520Li%2520J,%2520et%2520al.%2520Dietary%2520sugar%2520consumption%2520and%2520health:%2520umbrella%2520review.%2520BMJ.%2520(2023)%2520381:e071609.%2520doi:%252010.1136/bmj-2022-071609%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A39.%2520Krittanawong%2520C,%2520Qadeer%2520YK,%2520Wang%2520Z,%2520Nadolsky%2520K,%2520Virani%2520S,%2520Lavie%2520CJ.%2520Sugar-sweetened%2520and%2520artificially%2520sweetened%2520beverages%2520consumption%2520and%2520risk%2520of%2520cardiovascular%2520health.%2520Am%2520J%2520Med.%2520(2023)%2520136:163%25E2%2580%259371.%2520doi:%252010.1016/j.amjmed.2022.10.003%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A40.%2520Malik%2520VS,%2520Hu%2520FB.%2520Sugar-sweetened%2520beverages%2520and%2520cardiometabolic%2520health:%2520an%2520update%2520of%2520the%2520evidence.%2520Nutrients.%2520(2019)%252011:1840.%2520doi:%252010.3390/nu11081840%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A41.%2520Ax%2520E,%2520Warensjo%2520Lemming%2520E,%2520Becker%2520W,%2520Andersson%2520A,%2520Lindroos%2520AK,%2520Cederholm%2520T,%2520et%2520al.%2520Dietary%2520patterns%2520in%2520Swedish%2520adults;%2520results%2520from%2520a%2520national%2520dietary%2520survey.%2520Br%2520J%2520Nutr.%2520(2016)%2520115:95%25E2%2580%2593104.%2520doi:%252010.1017/S0007114515004110%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A42.%2520Piernas%2520C,%2520Mendez%2520MA,%2520Ng%2520SW,%2520Gordon-Larsen%2520P,%2520Popkin%2520BM.%2520Low-calorie-%2520and%2520calorie-sweetened%2520beverages:%2520diet%2520quality,%2520food%2520intake,%2520and%2520purchase%2520patterns%2520of%2520US%2520household%2520consumers.%2520Am%2520J%2520Clin%2520Nutr.%2520(2013)%252099:567%25E2%2580%259377.%2520doi:%252010.3945/ajcn.113.072132%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A43.%2520McLean%2520RM,%2520Farmer%2520VL,%2520Nettleton%2520A,%2520Cameron%2520CM,%2520Cook%2520NR,%2520Campbell%2520NRC.%2520Assessment%2520of%2520dietary%2520sodium%2520intake%2520using%2520a%2520food%2520frequency%2520questionnaire%2520and%252024-hour%2520urinary%2520sodium%2520excretion:%2520a%2520systematic%2520literature%2520review.%2520J%2520Clin%2520Hypertens%2520(Greenwich).%2520(2017)%252019:1214%25E2%2580%259330.%2520doi:%252010.1111/jch.13148%250APubMed%2520Abstract%2520%257C%2520Crossref%2520Full%2520Text%2520%257C%2520Google%2520Scholar%250A44.%2520Swedish%2520Board%2520of%2520Agriculture.%2520Food%2520Consumption%2520and%2520Nutritive%2520Values,%2520Data%2520Up%2520to%25202017.%2520Swedish%2520Board%2520of%2520Agriculture%2520(2018).%250AGoogle%2520Scholar%250A%250AKeywords:%2520added%2520sugar,%2520cardiovascular%2520disease,%2520dietary%2520sugars,%2520sugar-sweetened%2520beverages,%2520heart%2520disease%250ACitation:%2520Janzi%2520S,%2520Gonz%25C3%25A1lez-Padilla%2520E,%2520Ramne%2520S,%2520Bergwall%2520S,%2520Born%25C3%25A9%2520Y%2520and%2520Sonestedt%2520E%2520(2024)%2520Added%2520sugar%2520intake%2520and%2520its%2520associations%2520with%2520incidence%2520of%2520seven%2520different%2520cardiovascular%2520diseases%2520in%252069,705%2520Swedish%2520men%2520and%2520women.%2520Front.%2520Public%2520Health%252012:1452085.%2520doi:%252010.3389/fpubh.2024.1452085%250AReceived:%252020%2520June%25202024;%2520Accepted:%252008%2520October%25202024;%25E2%2580%25A8Published:%252009%2520December%25202024.%250AEdited%2520by:%250AFaraz%2520Siddiqui,%2520University%2520of%2520York,%2520United%2520Kingdom%250AReviewed%2520by:%250AJimmy%2520Chun%2520Yu%2520Louie,%2520Swinburne%2520University%2520of%2520Technology,%2520Australia%250AFarhana%2520Akter,%2520Chittagong%2520Medical%2520College,%2520Bangladesh%250AElham%2520Jamshidi,%2520Johns%2520Hopkins%2520University,%2520United%2520States%250ACopyright%2520%25C2%25A9%25202024%2520Janzi,%2520Gonz%25C3%25A1lez-Padilla,%2520Ramne,%2520Bergwall,%2520Born%25C3%25A9%2520and%2520Sonestedt.%2520This%2520is%2520an%2520open-access%2520article%2520distributed%2520under%2520the%2520terms%2520of%2520the%2520Creative%2520Commons%2520Attribution%2520License%2520(CC%2520BY).%2520The%2520use,%2520distribution%2520or%2520reproduction%2520in%2520other%2520forums%2520is%2520permitted,%2520provided%2520the%2520original%2520author(s)%2520and%2520the%2520copyright%2520owner(s)%2520are%2520credited%2520and%2520that%2520the%2520original%2520publication%2520in%2520this%2520journal%2520is%2520cited,%2520in%2520accordance%2520with%2520accepted%2520academic%2520practice.%2520No%2520use,%2520distribution%2520or%2520reproduction%2520is%2520permitted%2520which%2520does%2520not%2520comply%2520with%2520these%2520terms.%250A*Correspondence:%2520Suzanne%2520Janzi,%2520c3V6YW5uZS5qYW56aSYjeDAwMDQwO21lZC5sdS5zZQ%253D%253D%250A%250ADisclaimer:%2520All%2520claims%2520expressed%2520in%2520this%2520article%2520are%2520solely%2520those%2520of%2520the%2520authors%2520and%2520do%2520not%2520necessarily%2520represent%2520those%2520of%2520their%2520affiliated%2520organizations,%2520or%2520those%2520of%2520the%2520publisher,%2520the%2520editors%2520and%2520the%2520reviewers.%2520Any%2520product%2520that%2520may%2520be%2520evaluated%2520in%2520this%2520article%2520or%2520claim%2520that%2520may%2520be%2520made%2520by%2520its%2520manufacturer%2520is%2520not%2520guaranteed%2520or%2520endorsed%2520by%2520the%2520publisher.%250A%250AFooter%250A%2509%25E2%2580%25A2%2509Guidelines%25E2%2580%25A8%25E2%2580%25A8%250A%2509%25E2%2597%25A6%2509Author%2520guidelines%250A%2509%25E2%2597%25A6%2509Editor%2520guidelines%250A%2509%25E2%2597%25A6%2509Policies%2520and%2520publication%2520ethics%250A%2509%25E2%2597%25A6%2509Fee%2520policy%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509Explore%25E2%2580%25A8%25E2%2580%25A8%250A%2509%25E2%2597%25A6%2509Articles%250A%2509%25E2%2597%25A6%2509Research%2520Topics%250A%2509%25E2%2597%25A6%2509Journals%250A%2509%25E2%2597%25A6%2509How%2520we%2520publish%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509Outreach%25E2%2580%25A8%25E2%2580%25A8%250A%2509%25E2%2597%25A6%2509Frontiers%2520Forum%250A%2509%25E2%2597%25A6%2509Frontiers%2520Policy%2520Labs%250A%2509%25E2%2597%25A6%2509Frontiers%2520for%2520Young%2520Minds%250A%2509%25E2%2597%25A6%2509Frontiers%2520Planet%2520Prize%250A%2509%25E2%2580%25A2%2509%250A%2509%25E2%2580%25A2%2509Connect%25E2%2580%25A8%25E2%2580%25A8%250A%2509%25E2%2597%25A6%2509Help%2520center%250A%2509%25E2%2597%25A6%2509Emails%2520and%2520alerts%250A%2509%25E2%2597%25A6%2509Contact%2520us%250A%2509%25E2%2597%25A6%2509Submit%250A%2509%25E2%2597%25A6%2509Career%2520opportunities%250A%2509%25E2%2580%25A2%2509%250AFollow%2520us%250A%25C2%25A9%25202024%2520Frontiers%2520Media%2520S.A.%2520All%2520rights%2520reserved%250APrivacy%2520policy%2520%257C%2520Terms%2520and%2520conditions%250A%2509%25E2%2580%25A2%2509%250A%0A%3C/text%3E