Department of Epidemiology, Jiann-Ping Hsu College of Public Health, Georgia Southern University, Statesboro, Georgia, USAUnited States
Also available as PDF (figures and tables appear in the PDF).
Objective: To evaluate the association between depression and sugary drink intake using participant data from the Behavioral Risk Factor Surveillance Survey (BRFSS). Design: Cross-sectional data from the 2012 and 2013 BRFSS were examined (N=44,603). Depression was based on self-report of symptoms within the past 30 days. Covariates included age, sex, race, employment status, body mass index (BMI), education level, and exercise in the past 30 days. Setting: Data from a national telephone survey (BRFSS) were used to assess risk factors associated with health of the participants. Subjects: Participants in the 2012 and 2013 BRFSS were included in this analysis (N=44,603). Results: Adjusting for confounders, the odds of depression increased by 5% for every sugary drink consumed (odds ratio (OR)=1.06, 95% confidence interval (CI)=1.02-1.10). Depression was also associated with race, with non-Hispanic blacks being 60% more likely to be depressed than non-Hispanic whites. Unemployment and having a high school or less education were independently associated with depression. The association of depression and consumption of sugar sweetened beverages was stronger among women than men. Conclusion: This study indicates that consuming sugary drinks are associated with an increased odds of depression. These findings support advocacy efforts for an overall healthy lifestyle. In addition, future research should evaluate this association using a cohort design in order to establish the temporality of this association.
Keywords: Mental health; Epidemiology; Diet; Soda
Increased sugar intake has become a major concern in the United States over the past few de-
cades, with particular concern related to sugar sweetened beverages. Between 1977 and 1996
all age groups in the United States (US) more than doubled their consumption of sugary bever-
ages.1 In 2000, the average American citizen consumed 260 grams of sugar per day, although
of Agriculture (USDA) recommends no more than 40 grams per
According to the National Institutes of Health (NIH), 15.7 million adults reported having at
having an anxiety disorder, with 4% of these being classified as “severe”. The increased levels
of sugar intake and increased reporting of mental illness are both major public health concerns
in the US.
Overwhelming evidence suggests that added dietary
sugar has a negative impact on an individual’s mental health.
Research has provided many examples of sugar consumed ex-
cessively leading to altered mental health, however the associa-
tion between the concentrated sugar contents in manufactured
sugary beverages and depressive symptoms has not been exam-
ined. With the current increase in both sugary beverage intake as
well as reported depression in the US, the objective of this study
was to evaluate the possible association between sugary bever-
age intake and reported depression symptoms using data from
the Behavioral Risk Factor Surveillance System (BRFSS).
The BRFSS is a national telephone survey used to assess risk
factors associated with health of the participants.4 It is conducted
on an annual basis throughout the US. Response data for the
years 2012 and 2013 were included in this analysis.
For participants to be included in this analysis, answers for both
the outcome and exposure variables (described below) must
have been valid. Any missing responses to the aforementioned
variables excluded the participant from the analysis.
BRFSS participants were asked how often during the past month
they felt “so depressed that nothing could cheer (them) up?”.4,5
Participants who self-reported depression in this manner were
categorized as depressed.
The primary exposure for this analysis was intake of sugar
sweetened beverages. Two questions in the BRFSS provide
these data, asking participants to report their consumption in the
past 30 days:
1. “About how often do you drink regular soda or pop that con- 4,5 tains sugar?.”4,5
2. How often did you drink sugar-sweetened fruit drinks (such
as Kool-aid and lemonade), sweet tea, and sports or energy
drinks (such as Gatorade and Red Bull)?”.4,5
Participants were asked to not include 100 percent fruit
juice, diet drinks, or artificially sweetened drinks such as diet
soda or diet pop. Responses to these questions were standardized
to the number of drinks consumed per day and this variable was
considered continuous.
employment status, body mass index (BMI), education level,
and exercise in the past 30 days. Age was categorized as 18-
24, 25-34, 35-44, 45-54, 55-64, and 65+ years. Race was clas-
sified as Non-Hispanic white (reference group), Non-Hispanic
black, or other; employment status was categorized as employed
(employed for pay or self-employed) or not employed (retired,
student, homemaker or looking for work); education was coded
as high school or less or more than high school, and exercise
was dichotomized to indicate if the participant exercised at all
outside of their employment during the past month. BMI was
treated as a continuous variable and was calculated by BRFSS
based on participants’ self-reported weight and height. These co-
variates were considered as possible confounders.
The bivariate association between each covariate and
depression and sugar sweetened beverages (separately) was
evaluated using t-tests and Chi-square tests, as appropriate.
Means and standard errors (SE) were calculated for continuous
variables and frequencies were obtained for categorical vari-
ables. A logistic regression model was constructed to evaluate
the association between sugar sweetened beverages and depres-
sion, controlling for confounders. In addition to the model for the
entire sample, separate models were evaluated stratified by sex
in order to assess possible effect modification. Survey weights
were used throughout the analysis, which was performed using
SAS version 9.4.6 Survey procedures were used for mean, fre-
quency and logistic procedures.
4,5
Table 1 shows the unadjusted demographic distribution by de-
pression status. Among those depressed, more than 60% of the
study population was 44 years of age or older, income level was
fairly evenly distributed among the participants, education was
also fairly even for those obtaining a high school degree and
higher, some college or technical school and finishing college.
Those not participating in exercise reported depression more
frequently than those who did exercise (32.8% crude fibre (cf.)
20.1%, respectively), although the majority of both groups did
not exercise. There was also a lower percentage of employed and
retired individuals in the depressed group (43.5% of depressed
participants were employed and 18.7% were retired cf. 56.8%
employment and 28.0% retirement among non-depressed par-
ticipants); however in the depressed group there was also a large 4,5 percentage (18%) of individuals classified as “unable to work”.
After adjusting for confounders using logistic regres-
sion, it was found that drinking one sugary beverage per day
increases the likelihood of depression by 6% (OR=1.06, 95%
CI=1.02-1.10) (Table 2). Among other covariates, race was
most strongly associated with depression, with black non-His-
panics being approximately 60% more likely to be depressed
(OR=1.62, 95% CI=1.19-2.20) and other races being more than
twice as likely to be depressed (OR=2.16, 95% CI 1.79-2.62)
Male Female
18-24 25-34 35-44 45-54 55-64 65 and Older
Employed for Wages Self-employed Out of work for more than 1 year Out of work for less than a year A homemaker A student Retired Unable to work Missing=129
Less than 10,000 Less than 15,000 Less than 20,000 Less than 25,000 Less than 35,000 Less than 50,000 Less than 75,000 75,000 or more Missing=5,115
Never attended school or only kindergarten Grades 1 through 8 (elementary) Grades 9 through 11 (some high school) Grade 12 or GED (high school graduate) College 1 to 3 years College 4 years or more years Missing=95
White non-Hispanic Black non-Hispanic Asian non-Hispanic American Indian/Alaskan Native Hispanic Other race non-Hispanic
Yes No Missing=66
SE: Standard Error.
Table 1. Demographics.
ing a high school education or less were also associated with
depression status (OR=2.12, 95% CI=1.80-2.51; OR=1.89, 95%
CI=1.62-2.18, respectively).
Consistent with prior research, there also was a protec-
tive factor associated with exercise, as those who did not partake
in regular exercise, outside of their profession, were 71% more
likely to be depressed in comparison with their counterparts who
did exercise. This protective factor was also seen in individuals
of “retirement age” in the 65 years and older category, which is
2,119 (39.0%) 16,498 (42.1%) <0.0001 3,320 (61.0%) 22,666 (57.9%)
377 (6.9%) 1,829 (4.7%) 659 (12.1%) 3,869 (9.9%) 794 (14.6%) 5,068 (12.9%) <0.0001 1,236 (22.7%) 6,991 (17.6%) 1,246 (22.9%) 9,020 (23.0%) 1,127 (20.1%) 12,387 (31.6%)
1,988 (36.6%) 18,439 (47.1%) 373 (6.9%) 3,805 (9.7%) 354 (6.5%) 756 (1.9%) 269 (4.9%) 778 (2.0%) <0.0001 273 (5.0%) 2,101 (5.4%) 170 (3.1%) 857 (2.2%) 1,018 (18.7%) 10,980 (28.0%) 981 (18.0%) 1,332 (3.4%)
603 (11.1%) 1,114 (2.8%) 518 (9.5%) 1,451 (3.7%) 593 (10.9%) 2,229 (5.7%) 636 (11.7%) 3,086 (7.9%) <0.0001 607 (11.2%) 3,834 (9.8%) 616 (11.3%) 5,477 (14.0%) 557 (10.2%) 6,239 (15.9%) 729 (13.4%) 11,199 (28.6%)
16 (0.3%) 33 (0%) 209 (3.8%) 538 (1.4%) 466 (8.6%) 1,321 (3.4%) <0.0001 1,722 (31.7%) 10,211 (26.1%) 1,608 (29.6%) 11,494 (29.3%) 1,408 (25.9%) 15,482 (39.5%)
4,186 (80.0%) 34,561 (88.2%) 308 (5.7%) 1,142 (2.9%) 95 (1.7%) 530 (1.4%) <0.0001 182 (3.3%) 631 (1.6%) 473 (8.7%) 1,444 (3.7%) 195 (3.9%) 856 (2.2%)
1,783 (32.8%) 7,864 (20.1%) <0.0001 3,642 (67.2%) 31,248 (79.9%)
27.87±0.19 27.16±0.07 0.0004
1.12±0.13 0.62±0.02 <0.0001
also consistent with a greater percentage of non-depressed retir-
ees seen (Table 1).
It should also be noted that there was a greater percent-
age of women that self-reported depression with women having
a 17% greater chance of depressive symptoms. In the sex-strat-
ified analysis, the odds of depression was higher among women
than men, although the confidence intervals overlapped (Table
3). Contrary to the whole-group findings, age was not indepen-
dently associated with depression among women.
Sugary Beverages (#per day) 1.05 (1.02-1.08) 1.11 (1.01-1.22)
BMI 1.00 (0.97-1.02) 1.02 (1.01-1.04)
*Each measure is adjusted for other variables in table. CI: Confidence Interval; Ref: Reference group.
Sugary Beverages (#per day) 1.06 1.02-1.10
Male Ref
Female 1.17 1.01-1.36
18-24 years Ref
25-34 years 1.50 1.10-2.02
35-44 years 1.18 0.88-1.58
45-54 years 1.25 0.94-1.65
55-64 years 0.99 0.74-1.33
65+ years 0.43 0.31-0.59
White, non-Hispanic Ref
Black, non-Hispanic 1.61 1.18-2.19
Other 2.06 1.70-2.50
BMI 1.01 1.00-1.03
Employed for pay Ref
Not employed 2.12 1.79-2.51
More than high school Ref
High school graduate or less 1.78 1.53-2.02
Exercise 1.71 1.45-2.02
Yes Ref
No 1.71 1.45-2.02 *Each measure is adjusted for other variables in table. CI: Confidence Interval; Ref: Reference group.
Odds of depression (adjusted*) (n=44,243).
18-24 years Ref
25-34 years 2.19 (1.34-3.57) 1.09 (0.75-1.58)
35-44 years 1.47 (0.92-2.35) 1.03 (0.70-1.50)
45-54 years 1.75 (1.12-2.73) 0.97 (0.68-1.39)
55-64 years 1.64 (1.05-2.57) 0.66 (0.46-0.96)
65+ years 0.65 (0.40-1.05) 0.32 (0.21-0.49)
White, non-Hispanic Ref
Black, non-Hispanic 1.28 (0.78-2.12) 1.85 (1.24-2.76)
Other 1.96 (1.47-2.61) 2.03 (1.58-2.60)
Employed for pay Ref
Not employed 2.19 (1.66-2.88) 2.11 (1.71-2.60)
More than high school Ref
High school graduate or less 2.05 (1.66-2.53) 1.59 (1.28-1.97)
Yes Ref
No 1.30 (1.02-1.65) 2.05 (1.63-2.57)
Sex-specific Odds of Depression (adjusted*).
We found that sugary drink consumption was positively associ-
ated with depression, controlling for age, sex, and measures of
socio-economic status. For every sugary drink consumed daily,
the odds of depression increased by 5%. Depression was also
independently associated with younger age as well as race, with
non-Hispanic blacks being 60% more likely to be depressed than
non-Hispanic whites. There also appeared to be an effect modifi-
cation showing sugary sweetened beverages may have a greater
effect on women than men (OR=1.17).
This study is one of the few to compare men and wom-
en of all adult age groups, as well as to examine the direct as-
sociation between sugary drinks and depression. Previous stud-
ies have typically focused solely on youth or women, as well 7-14 as specific diets.7-14 An ecologic study evaluated the association
between major depression and national sugar consumption in
Korea, the US, France, Germany, Canada, and New Zealand and
found a positive correlation (p=0.004).7 Whitaker et al8 found a
significant association between depressive symptoms and satu-
rated fat and sugar intake (<0.05) and, although not statistically
significant, a positive association between depressive symptoms
and sweetened beverage consumption (p=0.06).
The association between sugar and depression is espe-
cially concerning in children and adolescents, as rates for both
are dramatically increasing in this age group. An Australian
study reported that individuals who consumed more than a half
litre of soft drinks per day had approximately a 60% greater risk
of having depression, stress, suicidal ideation, and psychological
distress than those who did not consume soft drinks.9 A cross-
sectional study in China of 12-19 year old students found an
association between soda intake and suicidal plans or attempts.
Individuals who consumed at least three soft drinks per day were
80% more likely to attempt suicide than non-consumers. Ad-
ditionally, a survey in 2005 in California reported 40% of 2-11
year old children consumed at least one soda per day. A sig-
nificant association between soda consumption and withdrawn
behavior, attention, and aggressive behaviors (p<0.05) has been
reported among urban 5-year olds, which may influence the oc-
currence of mental disorders as the children grow.12
High consumption of sugar may also affect women
differently than men. Women who consumed a traditional diet
based on vegetables, meats, fish, fruits, and whole grains were
shown to have a lower risk of having depression while those
who consumed a Western diet consisting of processed or fried
foods, refined grains, sugary products, and beer were more likely
to have depression (OR=1.52). An examination of BMI, spe-
cific food intake, and severity of depression reported that great-
er consumption of high-calorie sweet food, such as chocolate,
soda, and sweetened fruit drinks, were associated with depres-
sive symptoms (p<0.01) but not BMI. The opposite was true for high-calorie non-sweet food, such as fried foods, hamburgers,
and whole-milk, where there was an association between BMI
not caloric surplus plays a more significant role in depression.14
The large, nationally representative sample included in
the BRFSS is the primary strength of this study. However, there
were limitations in the methodology. Importantly, the survey
did not clearly define an amount for what constituted one drink.
Variables such as the particular sugar sweetened beverage, the
volume of beverage or sugar content contained in the beverage
can vary widely, leading to information bias. The results are fur-
ther limited by participants’ self-report of depressive symptoms
in lieu of a validated measure of depression. The BRFSS is a
national survey in which questions are categorized in modules and many modules are only offered semi-annually. Additionally,
variables included in the survey are generally limited to specific
options for response. Expanding these options would enhance
analytic options in future research. Due to the cross-sectional
nature of the data, the temporal relation between consumption of
sugary drinks and depression cannot be established and should
be further investigated.
7 8
Another limitation is that the BRFSS does not account
for the effects of caffeine. Caffeine can be found in many sugar
sweetened beverages, especially sodas and pops. The association
between sugar consumption and depression may be confounded
by caffeine intake. In 2011, Lucas et al15 investigated this issue,
surveying 50,739 US women with a mean age of 63 years who
were free from depressive symptoms at baseline. They prospec-
tively assessed caffeine and coffee consumption and depressive
symptoms. During the 10 year follow-up 2,607 incident cases of
depression were observed.
Consistent with established risk factors for depression,
we found employment status (OR=2.12), race (non-Hispanic
blacks (OR=1.61), and races other than non-Hispanic white
10 (OR=2.06)) accounted for the highest odds for development
of depression. Further analysis of these sub-populations could
11 establish more demographically deterministic information on
sugar and depression. Furthermore, because women were shown
to be an effect modifier, in the future it might be advantageous to
look at gender specifically when doing research on the topic.
The association among consumption of sugary sweetened bever-
ages and depression adds to the volume of evidence negatively
linking health and sugar. As policymakers look to advocate
against high sugar contents in both foods and beverages, this
data can provide additional support for their recommendations.
Lowering the allowable sizes of sugar sweetened beverages
available for purchase or informing consumers of the health
consequences of their beverage choices is important to begin to
reduce the prevalence and incidence of preventable morbidities.
This study was approved by the Institutional Review Board
(IRB) of Georgia Southern University.