How sweet it isn’t — drinking sugary drinks has been associated with a greater risk of death from cardiovascular disease, especially among women, according to a new report from the American Heart Association’s journal, Circulation.

What’s more, while swapping out one sugar-sweetened beverage a day, such as a soda or a sports drink, with an artificially-sweetened drink (using low-calorie or noncaloric sweeteners like Stevia, Splenda or NutraSweet) was associated with a slightly lower mortality risk, sipping too many artificial sweeteners gets risky too. Drinking four or more of those artificially-sweetened drinks was linked to a greater risk of death among women.

Previous studies have found a correlation between sweetened soft drinks and weight gain, as well as between sugary beverages and health problems related to weight gain, such as Type 2 diabetes and cardiovascular disease. A pair of reports drawn from the Framingham Heart Study (FHS) at Boston University Medical Center in 2017 linked sipping sugary drinks with poor memory and smaller brain volume — and a daily diet-soda habit was linked to a much higher risk of suffering stroke and dementia.

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But the new report by the American Heart Association and the Harvard T.H. Chan School of Public Health analyzed data from two large, longitudinal studies to determine whether guzzling sugar-sweetened beverages or artificially-sweetened beverages would be worse for life expectancy. Researchers studied 37,716 men in the Health Professionals follow-up study (which began in 1986) and 80,647 women in a Nurses’ Health Study (which began in 1976), controlling for other dietary factors, physical activity and body mass index (BMI).

Those who drank two or more sugary drinks a day were associated with a 31% increased risk of death from cardiovascular disease, and an 18% increased risk of cancer death in both men and women, compared to those who drank less than one sugar sweetened beverage a month. But when sorted by gender, the syrupy sips appeared especially harmful for women: Those who had more than two a day (with a serving defined as a standard glass, bottle or can) saw a 63% increased risk of early death, while men who did the same saw a 29% increase in risk. Cardiovascular disease was the leading cause of premature death, followed by cancer (primarily colon and breast cancer).

“Drinking water in place of sugary drinks is a healthy choice that could contribute to longevity,” said Vasanti Malik, lead author on the paper, in a statement. “Diet soda may be used to help frequent consumers of sugary drinks cut back their consumption, but water is the best and healthiest choice.”

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Drinking a typical 12-ounce can of soda adds between 140 and 150 calories on average, and 35 to 37.5 grams of sugar, the American Heart Association noted, naming sweetened drinks as the biggest source of added sugar in the average American’s diet.

But even replacing those drinks with low- or no-calorie drinks flavored with artificial sweeteners should be done in moderation. While replacing one sugar-sweetened beverage with one artificially-sweetened drink a day was associated with a 4% lower risk of overall mortality (and a 5% lower risk of cardiovascular disease death, and a 4% lower risk of cancer death), women who drank four or more artificially sweetened drinks a day, in particular, were associated with a higher risk of death.

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The researchers noted that this finding was not considered as strong as the possible association between sugary drinks and an increased risk of death, however, and requires further research. More research is also needed to understand why sweetened drinks appear to have such a harmful effect on women’s health, in particular. A study published in the journal Stroke last month also found that women age 50 and older who drink more than one artificially sweetened beverage a day have a higher risk of stroke, heart attack or early death.

Two of the biggest sweetened beverage makers, Coca Cola Co.

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  and PepsiCo

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 , did not respond to MarketWatch requests for comment by publication time.

The American Beverage Association, which describes itself as the voice for the non-alcoholic beverage industry in the U.S., responded in a statement to MarketWatch that: “Soft drinks, like all the beverages made by our industry, are safe to consume as part of a balanced diet. The sugar used in our beverages is the same as sugar used in other food products. We don’t think anyone should overconsume sugar, that’s why we’re working to reduce the sugar people consume from beverages across the country. Additionally, low- and no-calorie sweeteners have been repeatedly confirmed as safe by regulatory bodies around the world.”

It added that, “We are leveraging our strengths in marketing and innovation to interest people in options with less sugar and zero sugar and in smaller package sizes. We’re creating more drinks with less or no sugar and we’re making smaller bottle and can options more widely available while boosting consumer demand for these options through our marketing. Today, 50% of all beverages purchased contain zero sugar.”

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Indeed, soda consumption in the United States fell to a 31-year low in 2016, according to Beverage Digest. And people bought more bottled water than soda in 2017, gulping 13.2 billion gallons of water (up from just 9.5 billion in 2012) compared to 12.3 billion gallons of soda (which dropped from 13.3 billion gallons in 2012).

So sweetened beverage makers are diversifying their projects to suit healthier tastes. Pepsi acquired home seltzer maker SodaStream last year for $3.2 billion, as well as Bare Foods, which makes dried fruit and vegetable snacks, for an undisclosed price. It also announced last month that it snapped up Muscle Milk maker CytoSport. Coca-Cola has relaunched its Coke Zero and Diet Coke brands, and rolled out sparkling versions of its Dasani and SmartWater products last year — when it also acquired mineral water brand Topo Chico.

Sparkling water generated nearly $49 million in sales in 2018 alone, up 22% from the year before, Nielsen reports. And the sparkling water category — including beverages like club soda and seltzer — grew 54% in the past four years.

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