The Complex Relationship Between Fruit Juice and Heart Health

ByCheryl

Fruit juice is undoubtedly high in sugar. This bottle of Minute Maid orange juice (“never sweetened”) contains about a full day’s worth of “free sugar”!

(Free sugar is “added sugar” plus sugars naturally present in honey, syrups and fruit juices.)

Minute Maid orange juice, 45g sugar, no fibre.

Canada’s Heart & Stroke Foundation applauded the removal of fruit juice as a fruit equivalent in the 2019 update to Canada’s Food Guide.

But then in 2020, two big studies published surprising results: People who drank a small amount of fruit juice — less than a cup a day — were less likely to have strokes (or die from them) than those who didn’t!

I write mostly for people with heart concerns, but I think we can all agree that strokes — often caused by similar blood vessel blockages — are also worth preventing if possible.

And good to know: The juice drinkers in those studies were not more likely to develop type 2 diabetes or cardiovascular disease — CVD. (Diabetes is a major heart disease risk factor.)

So should we go back to drinking juice now? 🙄 The answer, like so much in nutrition, is nuanced.

The quick and simple answer

If you aren’t interested in the research or examples, the quick answer is that:

  • Whole fruit is your best bet (fresh or frozen)
  • Small amounts (up to about 1/2 – 3/4 cup per day) appear to be neutral or slightly beneficial
  • Orange, pomegranate, and beet juices are particularly rich in heart-friendly nutrients
  • A large daily intake of juice isn’t a great idea.

And make sure that the juice you buy is what you think it is. I share a few examples below that have fooled people.

How did juice become such a villain?

Back in the day we drank orange juice at the first sign of a cold. (Sorry Mom, a 2013 Cochrane Review found no effect “on the duration or severity of colds” when people were given vitamin C or a placebo after the onset of symptoms.)

But still, OJ helps you get potassium, folate, and of course, vitamin C, which we do need, cold or no cold. And it contains a compound called hesperidin, which has been shown to reduce triglycerides, cholesterol, blood pressure, and markers of inflammation. (Hint: It’s in the oranges too!)

But then there’s the sugar. Nearly as much as in a soft drink! And sugar we drink is consumed, digested, and absorbed much more quickly than sugar from solid food, as I discussed in my recent blog post about sugar.

Think about it. A medium-sized orange has about 12 grams of sugar. Could you eat four of them at a time? That would be the sugar equivalent of polishing off that bottle of OJ above.

In 2013 a big US cohort study found that while eating more whole fruit was associated with a lower risk of type 2 diabetes, fruit juice was linked to a higher risk. Then in 2019, another US study reported a 24% increase in mortality for every 12 ounces (1-1/2 cups) of juice consumed!

Seems like an open and shut case, but remember, these are observational studies, which have significant limitations, as I outlined in my sugar post. Interpret with caution. But for long-term outcomes in nutrition, they’re usually the best we have.

Hold on… juice might not be so bad

Journal of the American Heart Association study

Then in 2020 the Journal of the American Heart Association published a large meta-analysis (study compiling the results of multiple studies), which found that 100% fruit juice was “protective on CVD (cardiovascular disease) outcomes,” particularly for strokes, and that it was “associated with comparable CVD risk reduction as that of vegetables”!

What. Is. Happening? Which study to believe?

A meta-analysis like this is usually a better source of evidence than single studies like the ones above. But the authors reported low certainty in the evidence for juice. It opened the door to the possibility that juice wasn’t as problematic as previously thought.

Important to note: The highest fruit juice drinkers in this study were having about 125 grams (or 4 ounces — a half-cup). So they weren’t exactly guzzling jugs of OJ straight from the fridge.

European Journal of Nutrition study

But then another 2020 systematic review and meta-analysis, published in the European Journal of Nutrition, found that drinking up to 200 mL of fruit juice a day was linked to lower incidence of strokes, and 170 mL to fewer total cardiovascular events! (Both are about 3/4 cup.) Beyond that, the effect was neutral, but not harmful.

The authors of the second paper also analyzed relevant randomized controlled trials (RCTs), which are considered higher quality studies. Together, they suggested that drinking fruit juice can reduce blood pressure and improve artery health. That provided a plausible explanation for the observations about strokes.

They also found that juice was not associated with excess weight gain, diabetes, or coronary heart disease (that which results from blockages in the heart arteries).

It’s possible that these studies came to different conclusions because the subjects were drinking smaller amounts of juice — enough to deliver benefits from nutrients like hesperidin, but not enough to negatively affect weight gain or blood sugar.

So should we drink fruit juice for heart health?

That really depends on your preferences and unique health situation, especially when the research is so inconclusive.

But for cardiovascular health, I’d cautiously say that about a half-cup of 100% fruit juice appears to be okay, and may even be beneficial, especially for people who don’t otherwise get much fruit.

But if you have type 2 diabetes or high triglycerides, this might not be helpful. Whole fruit yes, but not juice (or smoothies).

Otherwise, if you enjoy a small glass a day, especially from relatively nutrient-rich juices like orange, pomegranate, or beet, go for it.

But make sure it’s actually (100%) juice!

If you do decide to keep juice in your routine, don’t be fooled by imposters. The ingredients should only be juices and perhaps harmless additives like citric acid, natural flavour, or vitamins.

What you don’t want is something like this…

Always check the ingredient list:

The tiny giveaway on the front of the bottle…

If you want cranberry juice, ideally look for something like this:

But be warned, pure cranberry juice tastes TART. Most people find it quite unpleasant, which is why it’s usually mixed with sugar or sweeter juices, like this:

That’s better than cranberry “cocktail,” but (white) grape and apple juice aren’t exactly nutrition powerhouses.

If you want the benefits of cranberry, the unsweetened juice isn’t so bad mixed with sparkling water or a splash of orange juice.

A few more to avoid:

What a scary looking ingredient list! Not to mention this:

Five percent!!! Pass.

Or this, which is packaged to look more wholesome:

The word “punch” should awaken your spidey senses. When in doubt, check the ingredients:

Can you imagine??? It’s called “Berry” Punch, but has less than 1% strawberry juice from concentrate.

(Not to mention an artificial sweetener — sucralose — in addition to enough high fructose corn syrup to deliver 24 grams of sugar per cup! The Coca-Cola Company should be ashamed.)

Don’t be fooled by coloured apple juice

Does this look like orange juice to you?

I recently ordered it online when I meant to buy orange juice. (It’s called “Orange Pure Breakfast.”)

But look at the ingredients!

Because they say “and/or” in that ingredient list, the exact order and combination of the various juices is disguised. There could be very little orange juice in it!

Walmart has one of these products too. Would it fool you?

At least in theirs orange juice comes first, without the “and/or.”

Grape and apple juice have some potassium, vitamins, and polyphenols (a category of antioxidant plant compounds), but they’re not as nutrient-rich as orange and other richly coloured juices. What they are is cheap and sweet.

Sugar content of various fruit juices

Here are a few examples, so you get a sense of how much sugar we’re talking about.

For context, the WHO and the Heart & Stroke Foundation suggest we keep free sugars to below 5-10% of our calories, which works out to 25-50 grams a day for someone taking in 2000 calories a day. You might need a bit more or less, but that’s a good ballpark daily target. (See my sugar post for more on that.)

All of these are for a half-cup (4 oz or 120 mL), unless otherwise noted.

Orange juice:

Remember, these are a half-cup unless otherwise noted. See how much easier it is to fit a small glass into a 25-50 gram budget?

Apple juice:

Cranberry drinks:

Vegetable juices:

Low-sodium vegetable juices:

And finally…

A half-cup of juice has 10-13 grams of free sugar, unless it’s something that doesn’t taste sweet, like unsweetened cranberry or vegetable juice.

The Oasis packages say “no added sugar ever (promise!),” but they don’t have to add sugar! It’s in the fruit, and once it’s juiced, with next to no fibre, it acts like any other liquid sugar in the body. That’s why the WHO and other health organizations look at the sugar in juice, whether it’s “added sugar” or not.

The reason 100% juice beats a fruit “cocktail” or “punch” is that the sugar comes with benefits: Vitamins, minerals, and other nutrients. Too much isn’t great, but a small amount may be fine.

(I featured Oasis because it’s bottled in Canada, but these numbers are typical of any brand.)

Frequently asked questions

Is fresh-squeezed more nutritious?

People often ask this question. While fresh-squeezed juice usually tastes better, the nutrition is pretty similar. In particular, the sugar content will be comparable, assuming you’re comparing fresh-squeezed to 100% juice.

Both are good sources of antioxidants, especially with orange juice. Some studies find that vitamin C is higher in fresh-squeezed, but on the other hand, some manufacturers add extra vitamin C to their juice.

Surprisingly, tests on 36 samples of orange juice found levels of the antioxidant hesperedin were highest in the industrial juices, perhaps “…due to the mechanical process of obtaining the juices.” (Most of this antioxidant is found in the pith.)

Another study found that hesperedin and other polyphenols were actually highest after 48 hours, in both fresh-squeezed and commercial juices!

So don’t worry if fresh-squeezed fruit juice isn’t happening in your kitchen. And if it is, it’s not a justification to drink more. Sorry! 🤷‍♀️

Should you make a smoothie instead?

It’s hard to make a blanket statement about smoothies, because everyone uses different ingredients. But when fruits like berries, mango, or banana are pureed rather than juiced, the fibre comes along for the ride, so that’s good!

If you make your own, just think about the same principles you’d use for planning a balanced breakfast. Use whole fruit more than juice. If you do juice, stick to a half-cup. Include protein-rich ingredients, like Greek yogurt or soy milk. Bonus points if you can slip in a vegetable, like baby spinach.

If you have blood sugar concerns, keeping to one serving of fruit (or juice) at a time can help. (A serving is usually a half-cup, but berries are so low in sugar that you could make it a cup.) Many people, by the time they blend up a banana, a handful of blueberries, and enough juice to make it smooth, end up with 4-5 servings of (liquified) fruit at one meal. Too much of a good thing!

Even if you don’t have trouble with blood sugars (yet), it’s still not a great idea to drink 4-5 servings of fruit on the drive to your desk job. Portion size my friend.

What about juice bar smoothies?

If you buy smoothies on the go, check the list of ingredients and nutrition facts if you can. Look for the same things you’d put in a smoothie at home. Watch out for fruit juice or frozen yogurt. They boost the sugar content but are commonly used because they’re less expensive than whole fruit and deliciously sweet.

Acai is a small dark purple berry found in the Amazon rain forest. Nutritionally, it’s a good source of polyphenols, fibre, and even healthy fats.

What’s in the Açai Avalanche? Probably a lot of açai, right? There’s no formal ingredient list, so it’s not necessarily in order by weight, but this description from the website gives us an idea of what’s in the product:

Which do you think it has more of, frozen yogurt or açai? 🤔 Here’s a clue: Acai has next to no sugar. Let’s look at the sugar content:

That’s a ridiculous amount of sugar for anyone not training for a marathon! If you really want one, order the snack size (31 grams of sugar) and give half away. I’m guessing it you’re paying for more frozen yogurt than açai.

This section wouldn’t be complete unless we looked at the label of a popular grocery store smoothie:

Like I always say, read the ingredient list! This one is tricky, full of parentheses, so I highlighted the main ingredients:

Are you surprised to see that there’s more apple puree and apple juice than berries?

You wouldn’t think so from the front of the bottle, but the ingredients must be listed in order by weight. We have no way of knowing how much blackberry and strawberry puree is in there.

(Learn more about smoothies in my Complete Guide to Freshii.)

Is vegetable juice any better?

Typically, vegetable juice is much lower in sugar, although it can be loaded with salt.

Twenty percent of your daily max sodium is an awful lot to get from a couple of servings of vegetables! (Normally they’d have next to none.)

It’s like making soup from tomato paste plus carrot and other juices and then adding nearly a quarter-teaspoon of salt to each serving.

So if you like V8, tomato, or other vegetable juices, try the low-sodium options — in a few weeks you’ll be used to the fresher taste and your heart will thank you!

(If you’ve been advised to limit potassium, be aware that low-sodium vegetable juices are often quite high in potassium.)

Finally, watch out for green juice products. They’re not always vegetable rich! Like the berry smoothie above, they will often use mostly apple or grape juice:

Before reading further, look at the front of the package and guess what’s in it.

Here’s the ingredient list:

It could be worse, but I think people buying a green smoothie expect more vegetables. The only one listed before the “2%” disclosure is cucumber juice!

Is beet juice special?

Perhaps! Beets are one of the few rich plant sources of nitrates, which are converted in the body to nitric oxide, which can relax arteries and lower blood pressure, improving blood flow. (It may also enhance athletic performance!)

Studies have also shown that beets and beet juice can lessen inflammation and oxidative stress, and support blood vessel health. (It doesn’t hurt that beets are also rich in antioxidants, fibre, and vitamins.)

You can buy 100% beet juice at most grocery stores, but I had to laugh at this product I found on Amazon.ca:

That’s a serious commitment to beet juice! But hey, it’s probably better for you than a glass of wine from a box. 😂

While beets are a vegetable, their juice has about the same sugar content as typical fruit juice.

Are the purported benefits strong enough to make a case for buying a box? (Or more reasonably, a bottle?)

It’s hard to say. As usual, we need more research — ideally a longer-term study to see what actually happens with heart attacks and longevity.

In the meantime, if you want to get the benefits of beets, and you’re not up for eating them every day, a half-cup of beet juice might support the health of your arteries without delivering too much sugar.

Should I pay for cold-pressed juice?

The claim is that cold-pressed, usually locally made, organic juice retains more nutrients. At upwards of $10 a bottle, I certainly hope so!

However, when researchers studied them in a lab, they observed “…no significant differences between cold-pressed and normal centrifugal juices in terms of the contents of bioactive compounds… and antioxidant capacity.”

Either way, they’ll have the downside of any juice: That darned sugar.

But on the plus side, some cold-pressed juice blends include more vegetables or lemon juice, so they’re often lower in sugar. Check the label to see.

That 333mL bottle is just under a cup and a half. If it was all apple juice it would have about 32 grams of sugar. So there must be a decent amount of spinach and kale juice in there. No way to know how much, but the vitamin K content is equivalent to about a cup of each. Not bad actually!

Still just 1 gram of fibre though. You could use this to supplement your intake of greens, but for the most part, let’s eat our veggies (and fruit)!

(And don’t drink the whole bottle at once. That’s three days worth if you do a half-cup a day.)

Are “superfood” juices worth it?

Would “superfood” juices like pomegranate, with its plentiful antioxidants, support better heart health?

First, “superfood” is just a marketing term. It has no legal or scientific meaning.

Second, despite being higher in antioxidants and other nutrients, sugar is still an issue. Take this POM juice for example.

At 34 grams per cup, or 17 grams per half-cup, it’s one of the highest juices for sugar! On the other hand, it is 100% pomegranate juice, which one study found to be the highest in antioxidants of 25 juices tested.

Do benefits like improvement of blood vessel health cancel out the sugar content? It’s hard to say. It would take a very big, long, expensive study to say for sure whether or not that’s the case.

In fact, the US Federal Trade Commission (FTC) ruled against POM Wonderful for making inadequately supported claims that its products could prevent or treat heart disease, among other concerns, so I’m pretty sure we don’t have that study yet.

If you like the idea of the antioxidants, you could go for a half-cup of 100% pomegranate juice daily, or better yet, crack open and enjoy a pomegranate! (Not always feasible I know.)

And with “superfood” products, be sure you’re getting what you think you’re getting.

How much açai do you think is in these açai + blueberry flavoured juice shots? There’s no way to know. But the ingredient lists confesses that it’s less than the apple and pineapple juice.

Here are the nutrition facts. What do you think?

It looks low right? But notice the serving size. (They’re sold in tiny bottles — 62 grams is about a quarter-cup.)

On the upside, it’s portion controlled! The sugar is equivalent to about 10 grams per half-cup, compared to about 13 grams for apple and pineapple juice.

Still, at $2.50 a pop, that’s a pretty expensive adult juice box!

Bottom line: Fruit is your friend. Juice, maybe

Doing the research for this reminded me how beneficial fruit is. So much nourishment in one little tasty food!

And a small (1/2 cup) daily glass of juice? It might be helpful, and it doesn’t seem to hurt. If that feels too small, you could try combining it with sparkling water.

If you want juice, consider more nutrient-dense options like orange, pomegranate, or even purple grape. Anything dark and richly coloured should be more nutrient-rich, but check that it’s not mostly apple or grape juice.

And eat your berries, oranges, apples, and more fruit when you can. 😉❤️

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