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Intake of Sugar-Sweetened Beverages and Fecundability in a North American Preconception Cohort

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Intake of Sugar-Sweetened Beverages and Fecundability in a North American Preconception Cohort ORIGINAL ARTICLE Intake of Sugar-sweetened Beverages and Fecundability in a North American Preconception Cohort Elizabeth E. Hatch,a Amelia K. Wesselink,a Kristen A. Hahn,a James J. Michiel,a Ellen M. Mikkelsen,b Henrik Toft Sorensen,b Kenneth J. Rothman,a,c and Lauren A. Wisea Background: Dietary factors, including sugar-sweetened beverages, pproximately 10%–15% of North American couples may have adverse effects on fertility. Sugar-sweetened beverages Aexperience infertility, defined as the inability to con- 1 were associated with poor semen quality in cross-sectional studies, ceive after 12 or more months of attempting pregnancy. and female soda intake has been associated with lower fecundability Both female and male factors contribute to infertility, with in some studies. estimates of 39% of cases due to a female factor alone, 20% Methods: We evaluated the association of female and male sugar- to a male factor, 33% to both male and female factors, and sweetened beverage intake with fecundability among 3,828 women 8% with unknown cause.2 Thus, identifying modifiable fac- planning pregnancy and 1,045 of their male partners in a North Ameri- tors in both partners that can improve fertility (e.g., diet) can prospective cohort study. We followed participants until pregnancy could help couples avoid expensive and stressful fertility or for up to 12 menstrual cycles. Eligible women were aged 21–45 treatments. (male partners ≥21), attempting conception for ≤6 cycles, and not using fertility treatments. Participants completed a comprehensive The amount of added sugar in the American diet 3 baseline questionnaire, including questions on sugar-sweetened bever- increased by 19% between 1970 and 2005. Much of this age consumption during the previous 4 weeks. We estimated time-to- increase stems from consumption of sugar-sweetened bev- pregnancy from follow-up questionnaires completed every 2 months erages, which on average supply 33% of total added sugar by the female partner. We calculated adjusted fecundability ratios intake.3 Sodas are the largest component of sugar-sweetened (FR) and 95% confidence intervals (CIs) according to intake of sugar- beverages in the United States.4 US intake of high fructose sweetened beverages using proportional probabilities regression. corn syrup (HFCS), the most common sweetener in sodas, Results: Both female and male intakes of sugar-sweetened beverages has increased substantially since 1970.5 Intake of HFCS in were associated with reduced fecundability (FR = 0.81; 95% CI = 0.70, Canada has also increased since 1994,6 but levels of other 0.94 and 0.78; 95% CI = 0.63, 0.95 for ≥7 sugar-sweetened beverages per week compared with none, for females and males, respectively). added sugars have declined over the last few decades, and 7 Fecundability was further reduced among those who drank ≥7 servings Canadians consume 50% less soda than US citizens. Soda per week of sugar-sweetened sodas (FR = 0.75, 95% CI = 0.59, 0.95 consumption has been linked to weight gain and type 2 dia- for females and 0.67, 95% CI = 0.51, 0.89 for males). betes,8,9 but few studies have investigated consumption of Conclusions: Sugar-sweetened beverages, particularly sodas and soda, either sugar-sweetened or diet, in relation to female or energy drinks, were associated with lower fecundability, but diet soda male fertility. Higher intake of sugar-sweetened beverages and fruit juice had little association. has been associated with earlier menarche10 and elevated 11 (Epidemiology 2018;29: 369–378) follicular estradiol, but not with anovulation. Sugar-sweet- ened beverages are important contributors to high glycemic Submitted April 18, 2017; accepted January 29, 2018. load diets,12 which in turn have been related to increased risk a From the Department of Epidemiology, Boston University School of Public of ovulatory infertility.13 Findings for female soda consump- Health, Boston, MA; bDepartment of Clinical Epidemiology, Aarhus Uni- 14–17 versity, Aarhus N, Denmark; CRTI Health Solutions, Research Triangle tion and fertility are mixed but, with the exception of a Park, NC. recent study in an infertility clinic population,18 most studies The computing code and deidentified data are available by contacting the first or last author. were designed primarily to evaluate caffeine, and have not Supported by NICHD (R21-HD072326, R01-HD086742, R03-HD090315, comprehensively evaluated sugar-sweetened beverages or and T32-HD052458). diet sodas and fertility. In males, three cross-sectional stud- The authors report no conflicts of interest. Supplemental digital content is available through direct URL citations ies reported an association between soda consumption and in the HTML and PDF versions of this article (www.epidem.com). poor semen quality,19–21 but semen quality may be a poor Correspondence: Elizabeth E. Hatch, Department of Epidemiology, Bos- proxy for male fecundity.22 Here, we use data from a pro- ton University School of Public Health, 715 Albany Street, Boston, MA 02118. E-mail: [email protected]. spective cohort study of North American pregnancy plan- ners to examine the association between female and male Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 1044-3983/18/2903-0369 preconception sugar-sweetened beverage consumption and DOI: 10.1097/EDE.0000000000000812 fecundability. Epidemiology • Volume 29, Number 3, May 2018 www.epidem.com | 369 Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Hatch et al. Epidemiology • Volume 29, Number 3, May 2018 METHODS Assessment of Time-to-pregnancy We estimated time-to-pregnancy (TTP) using data from Study Population the female questionnaires (screening, baseline, and follow- Pregnancy Study Online (PRESTO) is an ongoing up). Women reported their pregnancy attempt time (in months Internet-based cohort study of pregnancy planners from the and menstrual cycles) at baseline. Those with regular men- United States and Canada that began enrollment in June strual cycles were asked their usual menstrual cycle length. 2013. Couples are eligible if trying to conceive and not using For women with irregular cycles, we estimated cycle length contraception or fertility treatments. Female participants are based on date of LMP at baseline and on prospectively- 21–45 years of age; male partners are ≥21 years of age. The reported LMP dates during follow-up. We estimated TTP study methods are described elsewhere.23 Briefly, female par- in discrete cycles as follows: [(menstrual cycles of attempt ticipants complete a comprehensive web-based baseline ques- time at baseline) + [(LMP date from most recent follow-up tionnaire and are encouraged to invite their male partner to questionnaire − date of baseline questionnaire)/cycle length] complete a one-time baseline questionnaire. Ten days after + 1].26 Participants who did not complete any follow-ups completing the baseline questionnaire, participants complete (n = 443 females and 49 males) were assigned one cycle of a separate food frequency questionnaire (FFQ) developed by observation; their outcome information was imputed (see the National Cancer Institute.24,25 Women complete follow-up multiple imputation procedures below). questionnaires every 8 weeks up to 12 months or until con- ception, whichever comes first. Of the 4,856 women enrolled Assessment of Covariates through May 2017, we excluded 830 who had been attempting The female and male baseline questionnaires collected conception >6 cycles at entry, 155 with insufficient/implau- data on age, race/ethnicity, education, income, reproductive sible dates of last menstrual period (LMP), and 43 pregnant at history, cigarette smoking, caffeine and alcohol intake, sleep study entry, leaving 3,828 women in analyses of sugar-sweet- duration, perceived stress using the 10-item Perceived Stress ened beverage intake by women. A total of 2,126 of these Scale,27 depressive symptoms using the Major Depression women (56%) invited their male partners, of whom 1,045 Inventory,28,29 height, weight, physical activity, intercourse (49%) enrolled and were included in analyses of intake of frequency, and use of methods to improve chances of con- sugar-sweetened beverages by males. PRESTO was approved ception (e.g., charting cycles, monitoring cervical mucus). by the Institutional Review Board at Boston Medical Center Body mass index was calculated as weight (kg) divided by and all participants provided informed consent. height (m2). Total metabolic equivalents (METs) of physical activity were calculated by multiplying the average number Assessment of Sugar-sweetened Beverage of hours per week engaging in various activities by meta- Intake bolic equivalents estimated from the Compendium of Physi- On the baseline questionnaire, female and male par- cal Activities.30,31 Female dietary variables (i.e., total caloric ticipants reported their average soda consumption (number intake and Healthy Eating Index [HEI] score) were collected of 12-ounce servings per week) in the past month, selecting on the FFQ.32 from a list of popular sodas. Responses to an open-ended category for “other soda” were categorized as sugar- Data Analysis sweetened or diet. Total sugar-sweetened soda intake was Analyses were run separately among the 3,828 female calculated by summing the number of 12-ounce servings and the 1,045 male participants. Average weekly intake of of Coca-Cola, Pepsi, Mountain Dew, Dr. Pepper, Sprite, sugar-sweetened and diet sodas, sugar-sweetened energy Fanta,
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