Important food sources of fructose-containing sugars and incident gout: a systematic review and meta-analysis of prospective cohort studies

Abstract

Objective: Sugar-sweetened beverages (SSBs) are associated with hyperuricaemia and gout. Whether other important food sources of fructose-containing sugars share this association is unclear.

Design: To assess the relation of important food sources of fructose-containing sugars with incident gout and hyperuricaemia, we conducted a systematic review and meta-analysis of prospective cohort studies.

Methods: We searched MEDLINE, Embase and the Cochrane Library (through 13 September 2017). We included prospective cohort studies that investigated the relationship between food sources of sugar and incident gout or hyperuricaemia. Two independent reviewers extracted relevant data and assessed the risk of bias. We pooled natural-log transformed risk ratios (RRs) using the generic inverse variance method with random effects model and expressed as RR with 95% confidence intervals (CIs). The overall certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation system.

Results: We identified three studies (1 54 289 participants, 1761 cases of gout), comparing the highest with the lowest level of exposure for SSBs, fruit juices and fruits. No reports were found reporting incident hyperuricaemia. Fruit juice and SSB intake showed an adverse association (fruit juice: RR=1.77, 95% CI 1.20 to 2.61; SSB: RR=2.08, 95% CI 1.40 to 3.08), when comparing the highest to lowest intake of the most adjusted models. There was no significant association between fruit intake and gout (RR 0.85, 95% CI 0.63 to 1.14). The strongest evidence was for the adverse association with SSB intake (moderate certainty), and the weakest evidence was for the adverse association with fruit juice intake (very low certainty) and lack of association with fruit intake (very low certainty).

Conclusion: There is an adverse association of SSB and fruit juice intake with incident gout, which does not appear to extend to fruit intake. Further research is needed to improve our estimates.

Trial registration number: NCT02702375; Results.

Keywords: food sources of fructose containing sugars; fructose; gout; sugars; systematic review and meta-analysis; uric acid.

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1

Summary of evidence search and selection. Flow of the literature search for the effect of food sources of sugar intake on incident gout and hyperuricaemia. Of the 309 studies initially identified, 294 were excluded based on title and/or abstract. The remainder were read in full by two independent reviewers; after, 12 were further excluded. Included in this analysis were three prospective cohort studies.

Figure 2

Relation between intake of fruit, fruit juice and SSB incident gout. Estimates from most adjusted multivariate models accounting for food sources of fructose-containing sugars intake were used. The diamond represents the pooled effect estimate. Interstudy heterogeneity was tested using the Cochran Q statistic and quantified using the I2 statistic (I2 ≥50% indicative of significant heterogeneity). All results are presented as RR with 95% CI. OJ=orange juice. Other=other fruit juices. *The number of cases and participants are divided equally between the multiple entries of the study to ensure total count gives unique individuals. To overcome a unit-of-analysis error for studies appearing more than once in the same analysis, we readjusted the log-SEs to participants equally among the multiple comparisons. HPFS, Health Professionals Follow-up Study; NHS, Nurses’ Health Study; NRHS, National Runner’s Health Study; RR, risk ratio; SSB, sugar-sweetened beverage.