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Data Clearly Links Soda Consumption to Pancreatic Cancer | Natural Medicine Journal

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Data Clearly Links Soda Consumption to

Pancreatic Cancer
Risk of pancreatic cancer is linked to the consumption of soft drinks
and other forms of concentrated sugar
Special Thanks to Our Key Sponsors

By Jacob Schor, ND, FABNO

Reference

About The Author

Mueller NT, Odegaard A, Anderson K, et al. Soft drink and juice consumption
and risk of pancreatic cancer: the Singapore Chinese Health Study. Cancer
Epidemiol Biomarkers Prev. 2010;19(2):447-455.

Design
Prospective cohort study; information on consumption of soft drinks, juice, and
other dietary items, as well as lifestyle and environmental exposures, was
collected through in-person interviews at recruitment.
Jacob Schor ND, FABNO, is a

Participants

graduate of National College of

Naturopathic Medicine, Portland,

60,524 people taking part in the Singapore Chinese Health Study

Oregon, and now practices in

Denver, Colorado. He served as

Key Findings
Drinking two or more sodas a week almost doubles a persons risk of
developing pancreatic cancer. Following these people for 14 years yielded
648,387 person-years of data and 140 cases of pancreatic cancer (PC).
Individuals who consumed 2 or more soft drinks a week experienced a
statistically significant increase in risk of pancreatic cancer (hazard ratio, 1.87;
95% confidence interval, 1.103.15) compared with individuals who did not
consume soft drinks. There was no association seen between drinking fruit juice
and risk of PC.

president to the Colorado

Association of Naturopathic
Physicians and is now on the board
of directors of both the Oncology
Association of Naturopathic
Physicians and the American
Association of Naturopathic
Physicians. He is recognized as a
fellow by the American Board of
Naturopathic Oncology. He serves
on the editorial board for the
International Journal of Naturopathic

Practice implications

Medicine, Naturopathic Doctor News

This is just the latest in a series of studies on the subject that have yielded

Medicine: A Clinician's Journal. In

sometimes conflicting and confusing results. Yet the bottom line consensus

2008, he was awarded the Vis Award

appears to be that soda or other concentrated forms of sugar, such as candy

by the American Association of

bars, do increase risk of pancreatic cancer.

Naturopathic Physicians. His writing

and Review (NDNR), and Integrative

appears regularly in NDNR, the

Pancreatic cancer does not respond well to treatment: 5-year survival even with

Townsend Letter, and Natural

modern treatment is less than 5%. Therefore, prevention is the best approach.

Medicine Journal.

Cigarette smoking is the one accepted risk factor consistently associated with

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Data Clearly Links Soda Consumption to Pancreatic Cancer | Natural Medicine Journal

increased risk of pancreatic cancer. Type 2 diabetes also increases risk, which led to a theory that producing high levels of
insulin might somehow lead to malignant transformation of pancreatic cells.
In most cancers, the cells that become cancerous have been somehow overworked, irritated, or in some way abused before
becoming cancer cells. They have been pushed by something to grow faster, work harder, secrete more or in some manner
live harder lives. Estrogen pushes both breast and uterine cells to become cancerous. Testosterone pushes prostate cells to
become prostate cancer. Infections push lymph cells to become lymphoma. This theory about pancreatic cancer suggests
that high sugar intake pushes the pancreas.
Diabetes has been associated with pancreatic cancer for decades. A study on Seventh Day Adventists published in 1988
reported that prior history of diabetes was associated with increased risk of subsequent fatal pancreas cancer.1
A Kaiser Permanente study published that same year found that while cigarette smoking increased risk of pancreatic cancer
by a factor of 2.5, people who had been treated for diabetes had 4.5 times the risk. (Smoking: relative risk, 2.5; 95%
confidence interval, 1.34.7. Diabetes: relative risk, 4.5; 95% confidence interval, 1.216.7)2
A Dutch paper published in 1990 that analyzed data on 164 patients with pancreatic cancer found a significant, positive
association between pancreatic cancer and past habitual intake of simple sugars. (OR 1.95; 95% confidence interval, 1.24
3.07). This led the study authors to suggest that the development of exocrine pancreatic carcinoma is positively related to
past habitual intake of total energy, total carbohydrates, and simple sugars.3
A 1991 Australian paper that analyzed the habits of 104 people who developed PC also found a link to sugar consumption.
For the top quartile of refined sugar intake, the estimated relative risk was 2.21 (95% confidence interval, 1.074.55).4
A December 1995 study that looked at 179 cases of PC in French speaking Canadians found a similar effect of sugar
consumption. Again, high sugar consumption nearly tripled risk. Of interest in this paper was the pronounced effect of
cooking with firewood, a habit that increased relative risk by a factor of almost 5, while cooking in a pressure cooker lowered
risk to one-third the average.5
Sweetened carbonated drinks, what we call soft drinks, or soda, are a major source of simple sugars in western diets. As
such, soda consumption provides a measure of overall sugar consumption.6 Soda consumption is associated with
hyperglycemia and hyperinsulinemia, obesity, and type 2 diabetes.7,8
Rates of developing pancreatic cancer have plateaued and are stable in the United States, but they are rising among
Chinese men and women in Singapore.9 From 1968 to 1998, they have almost doubled (going from 3.7 to 5.4 per 100,000
for men and 1.5 to 3.4 per 100,000 for women). One explanation for this increase is the shift toward a more western diet and
increased consumption of sugar and sugar-sweetened sodas. It may be that during this transition period between traditional
diets and western diets, the effect of soda consumption is more pronounced. Soda may be adopted into the diet while
traditional foods and recipes still comprise the basic diet.
On the other hand, as soda consumption increases so do other behaviors linked to higher risk of pancreatic cancer. For
example in the Mueller study, people who drank more soda also consumed more red meat, total fat, sugar, candy, and
alcohol.
They smoked more, exercised less, and were more likely to become diabetic. Is soda the cause of the increased risk, or is it
just a marker of overall poor lifestyle?

They smoked more, exercised less, and

were more likely to become diabetic. Is soda
the cause of the increased risk, or is it just a
marker of overall poor lifestyle? The intricate
dissection of this data using statistical tools is
a delicate task. Simply gathering data on so
rare a cancer is itself a challenge.

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In the last 5 years, 4 other prospective cohort studies have been published that looked at this same equation of soda or
sugar consumption and whether it is tied to pancreatic cancer risk. Results from the current Mueller paper are consistent with
3 out of 4 of these earlier studies. One other study included fruit juice and found a positive association between juice intake
and PC risk; this current study did not find an association.
For their 2005 paper, Schernhammer and researchers from Harvard used data from 2 large cohortsthe Nurses Health
Study and the Health Professionals Follow-up Studycomprising 88,794 women and 49,364 men. These cohorts over the
course of 20 years follow-up yielded data on 379 cases of pancreatic cancer. Schernhammers analysis found that the
women who consumed more than 3 sodas a week had a 57% greater risk of pancreatic cancer than women who drank 1 or
fewer sodas per month. (RR, 1.57; 95% CI, 1.022.41; P for trend = 0.05). No association was found in the 174 men who
developed pancreatic cancer.10
In November 2006, the American Journal of Clinical Nutrition published a paper by Larsson, et al, analyzing Swedish dietary
data from a cohort of 77,797 people who were followed for 7 years, 131 of whom developed pancreatic cancer. Those who
drank 2 or more soft drinks per day had a 93% increased risk of pancreatic cancer. (OR 1.93 (1.18, 3.14; P for trend =
0.02)11,12
A November 2007 study conducted by Nothlings and fellow researchers from the University of Hawaii analyzed data for
162,150 participants in the Hawaii-Los Angeles Multiethnic Cohort Study to investigate associations between glycemic load,
dietary carbohydrates, sucrose, fructose, total sugars, and added sugars and the risk of pancreatic cancer. During 8 years of
follow-up, 434 pancreatic cancer cases occurred within the group. Again the results, though suggestive, contradict other
studies, at least in part. The risk of PC increased with higher intakes of total sugars, fructose, and sucrose. The association
with fructose was significant when the highest and lowest quartiles were compared (relative risk: 1.35; 95% CI: 1.02, 1.80; P
for trend = 0.046). An almost identical association was found with high fruit and juice intake (1.37; 1.02, 1.84; P for trend =
0.04), but no association was seen with soda intake. The researchers concluded that high fructose and sucrose intakes may
play a role in pancreatic cancer etiology. Conditions such as overweight or obesity in which a degree of insulin resistance
may be present may also be important.13,14
The Bao study published in 2008 is the one report that did not find an association between sugar and PC, despite the fact
that it was the largest of the studies. Rather than soda, the researchers calculated the total consumption of added sugar and
sugar-sweetened foods and beverages, examining data from 487,922 men and women, calculating total added dietary sugar
intake. During 7.2 years of follow-up, 1,258 pancreatic cancer cases were found within the group. The lowest sugar
consumers averaged about 3 tsp/day, while the high consumers averaged almost 23 tsp/day. No statistically significant
difference in risk was seen between these 2 groups. Thus these results did not support the sugar hypothesis.15,16
In August 2009, another study reported a positive but still confusing association. Chan and colleagues from the University of
California in San Francisco reported in the journal Cancer Causes and Control on a comparison of the dietary habits of 532
people who developed PC with people who didnt. Among men, greater intakes of total and specific sweets were associated
with pancreatic cancer risk that ranged from an overall risk of 1.9 for total sweets to 3.3 for candy bars, but the study did not
find sweets to be consistently associated with risk among women. In contrast to other soda studies, they also reported that
sweetened beverages were not associated with increased pancreatic cancer risk. But to confuse things further the authors
found low-calorie soft drinks were associated with increased risk among men.17
In November 2009 an Italian study was published that once again supported a link between sugar consumption and
pancreatic cancer. Polesel, et al, worked with data from 326 patients with pancreatic cancer comparing them to 652 control
patients. Comparing the diets of the 2 groups they found that frequent meat consumption was associated to a twofold
increased risk of pancreatic cancer (95% CI, 1.183.36). Added table sugar (OR = 2.23; 95% CI, 1.343.71) and potatoes
(OR = 1.79; 95% CI, 1.122.86) were related to pancreatic cancer. This led the authors to conclude that the increased risk
for table sugar suggests that insulin resistance may play a role in pancreatic carcinogenesis.18
Thus the Mueller study does not stand alone but is one of a series of studies that have parsed out this relationship between
sugar and pancreatic cancer. If we are to accept these findings, though, we need an explanation for this relationship.
There are 2 types of pancreatic cancer, endocrine and exocrine; endocrine tumors develop in the hormone-producing tissues
for secretion into the blood, while exocrine cancers develop from the tissues that make digestive enzymes for secretion into
the intestine. 95 percent of pancreatic tumors develop from the exocrine portion, including the ductal epithelium, acinar cells,
connective tissue, and lymphatic tissue.19 These exocrine-derived tumors are the focus of this discussion.
The endocrine and exocrine parts of the pancreas are not independent of each other; instead, they are functionally related,
and the endocrine gland profoundly affects the pancreass digestive activities. Blood and insulin are carried from insulinproducing cells to exocrine cells in what has been named the insulin-pancreatic acinar axis. Insulin regulates the exocrine
function of the pancreas. Exocrine cells are exposed to insulin concentrations that are 20-fold higher than in general
circulation. Insulin has an effect on these cells, increasing cell division and stimulating production of amylase.20,21 These

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Data Clearly Links Soda Consumption to Pancreatic Cancer | Natural Medicine Journal

high insulin levels may increase free insulin-like growth factor (IGF) by lowering levels of IGF-binding proteins. Low levels of
IGF-binding proteins are suggested in some research to be risk factor for pancreatic cancer.22 However, not all studies
support this idea; an August 2009 paper found no link between IGF-1 or IGF-binding proteins and PC.23
The Mueller paper found no association between fasting plasma insulin levels and pancreatic cancer risk. This suggests that
postprandial insulin may be a better measure for the association with cancer risk than fasting insulin levels and is consistent
with the independent role of soft drink consumption in the development of pancreatic cancer.24 In other words, it may be the
surge of insulin produced after eating concentrated sugars that is the problem.
Abandoning these soda studies for a moment, this idea that elevated insulin levels increase cancer risk is supported by a
paper published in September 2009 in Diabetologia. Currie and colleagues at Cardiff University looked for confirmation of
this insulin theory by looking at the effects of different blood sugarlowering treatments on type 2 diabetics.
They analyzed a retrospective cohort of 62,809 people who developed diabetes after age 40 and who were treated with
either oral agents or insulin. These patients were divided into 4 groups according to whether they received monotherapy with
metformin or sulfonylurea, combined therapy (metformin plus sulfonylurea), or insulin. The outcome measures were
progression to any solid tumor, or cancer of the breast, colon, pancreas, or prostate. Metformin monotherapy carried the
lowest risk of cancer. Adding metformin to insulin reduced progression to cancer. Compared with metformin, insulin therapy
increased the risk of colorectal or pancreatic cancer. Sulfonylureas were associated with a similar pattern of risk as insulin. It
appears anything that increases insulin levels increased risk of some cancers, especially pancreatic cancer.25
For more research involving integrative oncology, click here.

References
1. Mills PK, Beeson WL, Abbey DE, Fraser GE, Phillips RL. Dietary habits and past medical history as related to fatal pancreas cancer risk
among Adventists. Cancer. 1988;61(12):2578-2585.
2. Hiatt RA, Klatsky AL, Armstrong MA. Pancreatic cancer, blood glucose and beverage consumption. Int J Cancer. 1988;41(6):794-797.

Search

3. Bueno de Mesquita HB, Moerman CJ, Runia S, Maisonneuve P. Are energy and energy-providing nutrients related to exocrine

carcinoma of the pancreas? Int J Cancer. 1990 Sep 15;46(3):435-444.

4. Baghurst PA, McMichael AJ, Slavotinek AH, Baghurst KI, Boyle P, Walker AM. A case-control study of diet and cancer of the pancreas.
Am J Epidemiol.
CURRENT
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5. Ghadirian P, Baillargeon J, Simard A, Perret C. Food habits and pancreatic cancer: a case-control study of the Francophone community
in Montreal, Canada. Cancer Epidemiol Biomarkers Prev. 1995;4(8):895-899.
6. Guthrie JF, Morton JF. Food sources of added sweeteners in the diets of Americans. J Am Diet Assoc. 2000;100(1):43-51.
7. Harrington S. The role of sugar-sweetened beverage consumption in adolescent obesity: a review of the literature. J Sch Nurs.
2008;24(1):3-12.
8. Gibson S. Sugar-sweetened soft drinks and obesity: a systematic review of the evidence from observational studies and interventions.
Nutr Res Rev. 2008 Dec;21(2):134-147.
9. Mueller NT, Odegaard A, Anderson K, et al. Soft drink and juice consumption and risk of pancreatic cancer: the singapore chinese health
study. Cancer Epidemiol Biomarkers Prev. 2010;19(2):447-455.
10. Schernhammer ES, Hu FB, Giovannucci E, et al. Sugar-sweetened soft drink consumption and risk of pancreatic cancer in two
prospective cohorts. Cancer Epidemiol Biomarkers Prev. 2005;14(9):2098-2105.
11. Larsson SC, Bergkvist L, Wolk A. Consumption of sugar and sugar-sweetened foods and the risk of pancreatic cancer in a prospective
study. Am J Clin Nutr. 2006;84(5):1171-1176.
12. Ibid.
13. Nthlings U, Murphy SP, Wilkens LR, Henderson BE, Kolonel LN. Dietary glycemic load, added sugars, and carbohydrates as risk
factors for pancreatic cancer: the Multiethnic Cohort Study. Am J Clin Nutr. 2007;86(5):1495-1501.
14. Ibid.
15. Bao Y, Stolzenberg-Solomon R, Jiao L, et al. Added sugar and sugar-sweetened foods and beverages and the risk of pancreatic cancer
in the National Institutes of Health-AARP Diet and Health Study. Am J Clin Nutr. 2008;88(2):431-440.
16. Ibid.
17. Chan JM, Wang F, Holly EA. Sweets, sweetened beverages, and risk of pancreatic cancer in a large population-based case-control
study. Cancer Causes Control. 2009 Aug;20(6):835-846.
18. Polesel J, Talamini R, Negri E, et al. Dietary habits and risk of pancreatic cancer: an Italian case-control study. Cancer Causes Control.
2009 Nov 29. [Epub ahead of print]
19. 19. Erickson RA, Larson CR, Shabahang M. Pancreatic Cancer. http://emedicine.medscape.com/article/280605-overview. Accessed
February 26, 2010.
20. 20. Williams JA, Goldfine ID. The insulin-pancreatic acinar axis. Diabetes. 1985;34(10):980-986.
21. 21. Henderson JR, Daniel PM, Fraser PA. The pancreas as a single organ: the influence of the endocrine upon the exocrine part of the
gland. Gut. 1981;22(2):158-167.
22. Wolpin BM, Michaud DS, Giovannucci EL, et al. Circulating insulin-like growth factor binding protein-1 and the risk of pancreatic cancer.
Cancer Res. 2007;67(16):7923-8.

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23. Wolpin BM, Michaud DS, Giovannucci EL, et al. Circulating insulin-like growth factor axis and the risk of pancreatic cancer in four
prospective cohorts. Br J Cancer. 2007;97(1):98-104.
24. Mueller NT, Odegaard A, Anderson K, et al. Soft drink and juice consumption and risk of pancreatic cancer: the singapore chinese health
study. Cancer Epidemiol Biomarkers Prev. 2010;19(2):447-455.

25.
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Currie CJ, Poole CD, Gale EA. The influence of glucose-lowering therapies on cancer risk in type 2 diabetes. Diabetologia.
2009;52(9):1766-1777.

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