Habitual intake of fruit juice predicts central blood pressure

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Research report

Habitual intake of fruit juice predicts central blood pressure ☆ Q3 Matthew P. Pase a,*, Natalie Grima b, Robyn Cockerell a, Andrew Pipingas a a

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b

Centre for Human Psychopharmacology, Swinburne University of Technology, Australia Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia

A R T I C L E

I N F O

Article history: Received 8 November 2013 Received in revised form 11 July 2014 Accepted 21 September 2014 Available online Keywords: Fruit juice Blood pressure Central pressure Hypertension Diet Sugar

A B S T R A C T

Despite a common perception that fruit juice is healthy, fruit juice contains high amounts of naturally occurring sugar without the fibre content of the whole fruit. Frequent fruit juice consumption may therefore contribute to excessive sugar consumption typical of the Western society. Although excess sugar intake is associated with high blood pressure (BP), the association between habitual fruit juice consumption and BP is unclear. The present study investigated the association of fruit juice consumption with brachial and central (aortic) BP in 160 community dwelling adults. Habitual fruit juice consumption was measured using a 12 month dietary recall questionnaire. On the same day, brachial BP was measured and central (aortic) BP was estimated through radial artery applanation. Frequency of fruit juice consumption was classified as rare, occasional or daily. Those who consumed fruit juice daily, versus rarely or occasionally, had significantly higher central systolic BP (F (2, 134) = 6.09, p < 0.01), central pulse pressure (F (2, 134) = 4.16, p < 0.05), central augmentation pressure (F (2, 134) = 5.98, p < 0.01) and central augmentation index (F (2, 134) = 3.29, p < 0.05) as well as lower pulse pressure amplification (F (2, 134) = 4.36, p < 0.05). There were no differences in brachial BP. Central systolic BP was 3–4 mmHg higher for those who consumed fruit juice daily rather than rarely or occasionally. In conclusion, more frequent fruit juice consumption was associated with higher central BPs. © 2014 Elsevier Ltd. All rights reserved.

41 Introduction

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Fruit juice is generally considered to be a source of vitamins and antioxidants (Ruxton, Gardner, & Walker, 2006), creating a perception that fruit juice is healthy (Kim & House, 2014). Despite containing vitamins, fruit juice includes high amounts of naturally occurring sugar. Some fruit juices also contain added sugar. Along with sugar sweetened beverages such as soft drinks, fruit juice is a large contributor to daily sugar intake (Huth et al., 2013). According to the United States Department of Agriculture, a fresh medium size apple contains around 19 g of sugar (fructose/glucose ratio of 2) but also 4 g of dietary fibre (Agriculture USDo, 2012). A glass or bottle of apple juice may contain the natural sugar of multiple apples without the fibre content of the whole fruit, necessary to activate a satiety response. The health consequences associated with fructose consumption in sugar sweetened beverages has been the subject of recent controversy. Some have argued that fructose has toxic effects on the body, comparable with that of ethanol (Lustig, 2013). It has also been

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☆ Acknowledgements: Swisse Wellness funded the current investigation as part of a larger clinical trial. Conflict of interest: Andrew Pipingas is currently a member of the Scientific Advisory Panel for Swisse Wellness Pty Ltd. * Corresponding author. E-mail address: [email protected] (M.P. Pase).

suggested that excessive fructose consumption may cause detrimental health outcomes, such as metabolic syndrome and diabetes (Johnson et al., 2009). However, others have argued that the available evidence is insufficient to suggest that fructose consumption is responsible for metabolic diseases and obesity (van Buul, Tappy, & Brouns, 2014). There is thus a need for more research into the effects of sugar, and sugar containing products, on all aspects of human health. The daily consumption of soft drinks, which are high in fructose, have been linked to higher blood pressure (BP) (Dhingra et al., 2007), raising the question as to whether daily fruit juice consumption is also linked to high BP. Randomized, controlled trials in the area have provided little information on the subject. A recent metaanalysis of randomized, controlled trials reported no effect of fruit juice supplementation on systolic BP, despite a small reduction in diastolic BP (Liu et al., 2013). However, the majority of the reviewed studies tended to be of very short duration (2 weeks to 3 months) and poor methodological quality. A previous observational study reported no association between fruit juice consumption and brachial BP in a Western population (Griep et al., 2013). However, to our knowledge, the association between fruit juice consumption and central (aortic) BP has not been investigated. This association is important to examine because higher central BP is associated with adverse health outcomes such as cardiovascular events and mortality (Vlachopoulos et al., 2010) as well as impaired brain function (Pase et al., 2013). Moreover, some dietary factors, such

http://dx.doi.org/10.1016/j.appet.2014.09.019 0195-6663/© 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Matthew P. Pase, Natalie Grima, Robyn Cockerell, Andrew Pipingas, Habitual intake of fruit juice predicts central blood pressure, Appetite (2014), doi: 10.1016/j.appet.2014.09.019

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as caffeine, cocoa and dark chocolate, have been associated with central BP without observable differences in brachial BP (Karatzis et al., 2005; Vlachopoulos et al., 2005, 2007). The fish oil multivitamin (FMV) study is an Australian clinical trial that examined the health effects of dietary supplements in adults aged 50 to 70 years (N = 160). We used baseline data from this clinical trial to investigate whether fruit juice consumption was related to brachial BP and central BP, including indices of aortic stiffness and wave reflection. Information on fruit juice consumption was obtained from an in-house food frequency questionnaire asking about dietary patterns over the past 12 months. We hypothesized that those who consumed fruit juice on a daily basis would have higher BP (brachial and central) than those who consumed fruit juice occasionally or rarely.

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Method

Such categories were created to simplify the data and because they make theoretical sense. That is to say that it is easy to conceptualize the difference between consuming fruit juice daily versus no more than a few times a month. Brachial BP Brachial BP was measured using a standardized protocol and a validated automatic Omron, 705IT Sphygmomanometer (Omron Healthcare, Hoofddorp, The Netherlands) (Coleman et al., 2006; El Assaad, Topouchian, & Asmar, 2003). Participants were rested in a seated position for 5 minutes before having three sequential BP measurements taken from their left arm. The average of the three measurements was used in statistical analysis. Central (aortic) BP

The sample comprised 160 community dwelling male and female volunteers aged 50 to 70 years. Participants were all recruited from the general population by way of newspaper and radio advertisements, flyer drops and word of mouth. All participants were independently living. Eligibility was dependent on not having a history of neurological or psychiatric illness (i.e. epilepsy, dementia, depression, schizophrenia, traumatic brain injury), cardiovascular disease (CVD; i.e. stroke, heart failure, coronary heart disease) or diabetes. Being a current smoker or having a history of alcohol or drug abuse were also grounds for exclusion. Full eligibility criteria has been detailed elsewhere (Pase et al., in press; Pipingas et al., 2014). Participants were screened for the exclusion criteria in a faceto-face interview by a research assistant.

Measures Food frequency questionnaire Information on dietary patterns was taken from an in-house food frequency questionnaire. Participants were required to recall and respond according to how often they consumed different foods and beverages over the previous 12 months. When making responses to the different items, participants were asked to think back over the last 12 months and to think carefully about all eating occasions; including their usual weekday and weekend eating patterns, foods and beverages consumed away from home and when on holiday as well as those foods prepared and consumed at home. Categories of food and beverages that were examined included dairy foods, breads and cereals, meat, fish and eggs, vegetables, fruit, baked goods and snacks, spreads and dressings, non-milk beverages and dietary supplements. In the non-milk beverage section, a single item asked participants to indicate how often they consumed fruit juice by responding never, less than once per month, 1–3 times per month, once per week, 2–4 times per week, 5–6 times per week, once per day, 2–3 times per day, more than 3 times a day. This fruit juice item, and the range of possible responses, was consistent with another validated food frequency questionnaires (Hodge et al., 2000). Responses for the fruit juice consumption item were then grouped into broader categories of: (1) Rare use (combining scores from never use to no more than 3 times a month). (2) Occasional use (combining scores from once per week to 5–6 times per week).

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Participants

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(3) Daily use (combining scores from once per day to more than 3 times a day).

Central BP was measured because studies have shown that some dietary interventions can have measurable effects on central BP, without observable effects on brachial BP (Karatzis et al., 2005; Vlachopoulos et al., 2005, 2007). Central BPs also provide an indirect assessment of aortic stiffness (Laurent et al., 2006) and are useful predictors of CVD risk (Vlachopoulos et al., 2010). In the present study, central BP was measured using applanation tonometry of the radial artery (SphygmoCor device, AtCor Medical, Sydney, Australia) as follows: Immediately following the assessment of brachial BP, the participant remained seated. Brachial BP was then entered into the SphygmoCor software for calibration purposes. A small pressure sensitive pencil-like probe was then used to gently flatten (applanate) the radial artery, near the participant’s wrist. After obtaining a good signal, the SphygmoCor system recorded and averaged the radial artery waveform over numerous heart beats. Central BP was then automatically estimated by the software through waveform analysis using a validated mathematical algorithm (Chen et al., 1997). Numerous indices were calculated including central systolic BP, central diastolic BP, central pulse pressure, pulse pressure amplification (PPA), augmentation pressure and augmentation index (AIx). These are described below. As the heart beats, forward pressure waves travel from the aorta down to the arterial tree. Some of these pressure waves become reflected and travel back towards the heart. Aortic stiffness is directly proportional to the speed of these pressure waves (Nichols, O’Rourke, & Vlachopoulos, 2011). When aortic stiffness is low, the pressure waves travel slowly and arrive back at the heart during diastole. When aortic stiffness is high, the speed of wave propagation increases meaning that reflected pressure waves arrive back at the heart during the systolic part of the cardiac cycle. Such early returning pressure waves thus augment the central systolic BP and the central pulse pressure (central systolic – central diastolic BP) (Nichols et al., 2011). Augmentation pressure represents the amount the central systolic BP is augmented by reflected arterial pressure waves. AIx expresses the augmentation pressure as a percentage of the pulse pressure. It is thus a composite measure of wave reflection and aortic stiffness (Laurent et al., 2006). Higher AIx is associated with greater CVD risk (Vlachopoulos et al., 2010). Due to aortic stiffening, the systolic BP and pulse pressure increases more with age in the aorta than in the brachial artery (McEniery et al., 2005). PPA (brachial/aortic pulse pressure) captures the ratio between pulse pressure in the peripheral and central arteries. It is an indirect measure of aortic stiffness and arterial ageing and is a useful predictor of CVD risk (Benetos et al., 2010). As PPA diminishes with advancing age, due to the disproportion increase in central rather

Please cite this article in press as: Matthew P. Pase, Natalie Grima, Robyn Cockerell, Andrew Pipingas, Habitual intake of fruit juice predicts central blood pressure, Appetite (2014), doi: 10.1016/j.appet.2014.09.019

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Table 1 Sample means and standard deviations stratified by fruit juice consumption.

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Frequency of fruit juice consumption

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Rarely

Occasionally

Daily

Total

74 35.1 58.88 (5.94) 169.91 (10.23) 72.22 (12.83)

48 56.3 59.73 (5.48) 171.37 (9.22) 73.08 (15.27)

24 66.7 59.46 (5.07) 173.86 (6.12) 76.29 (13.85)

146 47 59.25 (5.63) 171.04 (9.39) 73.17 (13.81)

67.03 (9.75) 3.29 (0.70)* 1.68 (0.40)* 1.11 (0.57) 2.7 4.1

66.40 (11.26) 3.33 (0.72) 1.47 (0.36) 1.21 (0.55) 2.1 0

63.71 (12.74) 3.73 (0.81) 1.40 (0.33) 1.40 (0.77) 8.3 4.2

66.27 (10.78) 3.37 (0.74) 1.56 (0.39) 1.19 (0.61) 3.0 2.4

122.08 (18.33) 76.64 (11.45) 46.45 (10.58)

124.69 (19.34) 76.98 (11.03) 47.71 (11.51)

130.52 (20.56) 78.74 (12.10) 51.78 (11.77)

124.28 (19.13) 76.57 (11.39) 47.71 (11.16)

112.89 (16.36)* 76.50 (11.45) 36.39 (8.74)* 9.89 (4.62)** 26.76 (9.01)* 1.28 (0.13)

113.90 (16.68)** 77.54 (11.23) 36.35 (8.10)* 9.60 (4.91)** 25.99 (11.53) 1.32 (0.17)*

121.65 (19.39) 79.48 (12.15) 42.17 (10.88) 12.70 (4.61) 29.54 (5.27) 1.24 (0.09)

114.61 (17.14) 77.32 (11.46) 37.30 (9.10) 10.24 (4.81) 26.95 (9.50) 1.29 (0.14)

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Demographic N Males, % Age, years Height, cm Weight, kg Clinical Heart rate, bpm LDL, mmol/L HDL, mmol/L TC, mmol/L Treat BP, % Treat lipids, % Brachial pressures Systolic BP Diastolic BP Pulse pressure Central pressures Systolic BP Diastolic BP Pulse pressure AP AIx PPA

Note: LDL = low density lipoprotein cholesterol, HDL = high density lipoprotein cholesterol, TC = triglycerides, BP = blood pressure, AP = augmentation pressure, AIx = augmentation index, PPA = pulse pressure amplification. Group is significantly different to daily intake group at *p < 0.05 or **p < 0.001.

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than brachial pulse pressure, lower values of PPA are associated with higher CVD risk.

Sample characteristics

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Procedure Participants attended testing at Swinburne University of Technology, Melbourne, Australia. All participants presented for testing after abstaining from alcohol and caffeine for at least 12 hours. Data for the present study were collected as part of a larger clinical trial registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12611000094976). The study reported here only reports on data obtained during the baseline visit. All aspects of this study were approved by the Swinburne University Human Research Ethics Committee (project number 2010/051) and the research was conducted in accordance with the Declaration of Helsinki.

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Results

Statistical analysis Separate Univariate Analysis of Co-Variance (ANCOVA) models were used to examine whether the frequency of fruit juice consumption (rare, occasional and daily) was associated with each BP variable. Where significant main effects were found, planned comparisons, applying Bonferroni corrections, were used to examine significant differences between the rare, occasional and daily intake groups. Statistical models involving the BP variables were adjusted for age, gender, height, weight, mean arterial pressure, heart rate, treatment for lipids and treatment for hypertension. Models were adjusted for these specific covariates because they are all important predictors of brachial BP, central BP, or both (McEniery et al., 2005; Nichols et al., 2011). A post-hoc sensitivity analysis was conducted with the additional adjustment of LDL and HDL cholesterol. The purpose of this additional analysis was to examine whether associations between fruit juice consumption and BP were due to differences in cholesterol. All results were deemed significant at p < 0.05.

One hundred and forty-six participants completed questions pertaining to fruit juice consumption and were included in the analysis. The sample contained an even proportion of males and females with a mean age of 59 (SD = 6) years. Across the sample, the mean brachial systolic and diastolic BPs were 124 mmHg (SD = 19) and 77 mmHg (SD = 11) respectively. The mean central systolic and diastolic BPs were 115 mmHg (SD = 17) and 77 mmHg (SD = 11). The only beverages that were consumed on a daily basis by at least 15% of the sample were fruit juice, caffeinated coffee, caffeinated tea and herbal tea. Soft drinks, cordial and energy drinks were not widely consumed on a daily basis suggesting that the sample was relatively health conscious. As reported elsewhere (Pipingas et al., 2014), the cohort tended to have low blood levels of Omega-3 but high levels of saturated and monounsaturated fats, when compared to available reference values (Harris et al., 2013). Table 1 presents the demographic variables stratified according to fruit juice consumption. Analysis of variance showed that LDL cholesterol was higher (F (2, 143) = 3.42, p < 0.05) and HDL was lower (F (2, 143) = 7.14, p = 0.001) in those who consumed fruit juice daily as compared to rarely. The fruit juice intake groups were well matched across the other demographic variables.

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Primary analysis Those who consumed fruit juice daily had significantly higher central systolic BP (F (2, 134) = 6.09, p < 0.01) and augmentation pressure (F (2, 134) = 5.98, p < 0.01) as compared to those who consumed fruit juice rarely or occasionally. The estimated marginal means (Table 2) showed that those who consumed fruit juice on a daily basis had a central systolic BP that is 3 mmHg and 4 mmHg higher than those who consumed fruit juice rarely or occasionally respectively. The daily consumption of fruit juice was also associated with

Please cite this article in press as: Matthew P. Pase, Natalie Grima, Robyn Cockerell, Andrew Pipingas, Habitual intake of fruit juice predicts central blood pressure, Appetite (2014), doi: 10.1016/j.appet.2014.09.019

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Table 2 Estimated marginal means and standard errors for the cardiovascular variables stratified by fruit juice consumption.

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Frequency of fruit juice consumption

ANCOVA

Rarely

F

Occasionally

Daily

p

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Brachial pressures Systolic BP 124.22 (0.63) 123.81 (0.78) 125.47 (1.13) 0.75 0.476 Diastolic BP 76.61 (0.32) 76.81 (0.39) 75.98 (0.56) 0.75 0.476 Pulse pressure 47.61 (0.95) 47.01 (1.17) 49.49 (1.69) 0.75 0.476 Central pressures Systolic BP 114.60 (0.54)* 113.31 (0.67)** 117.39 (0.97) 6.09 0.003 Diastolic BP 77.47 (0.35) 77.35 (0.43) 76.77 (0.62) 0.49 0.616 40.62 (1.34) 4.16 0.018 Pulse pressure 37.14 (0.75) 35.96 (0.93)* AP 9.85 (0.42)** 9.70 (0.52)** 12.63 (0.75) 5.98 0.003 AIx 25.98 (0.89)* 26.67 (1.10) 30.64 (1.58) 3.29 0.040 PPA 1.29 (0.01) 1.31 (0.02)* 1.23 (0.02) 4.36 0.015

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Note: BP = blood pressure, AP = augmentation pressure, AIx = augmentation index, PPA = pulse pressure amplification. Group is significantly different to daily intake group at *p < 0.05 or **p < 0.001. All ANCOVA models were adjusted for age, gender, height, weight, mean arterial pressure, heart rate, treatment for lipids and treatment for hypertension.

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lower PPA (F (2, 134) = 4.36, p < 0.05) and higher central pulse pressure (F (2, 134) = 4.16, p < 0.05) compared to those who consumed fruit juice on an occasional basis and a higher augmentation index (F (2, 134) = 3.29, p < 0.05) compared to those who consumed fruit juice on a rare basis. The pattern of results was unchanged when excluding those receiving treatment for hypertension (data not shown). Sensitivity analysis Given that LDL cholesterol was higher and HDL cholesterol was lower in those who consumed fruit juice daily as compared to rarely, we decided to perform post-hoc ANCOVAs to examine whether associations between fruit juice consumption and BP were explained by LDL and HDL cholesterol. After stepping LDL and HDL cholesterol into the statistical models, fruit juice consumption remained a significant predictor of central systolic BP, central pulse pressure, central augmentation pressure and PPA, but not AIx (Table 3). Discussion This study investigated the effects of habitual fruit juice consumption, measured through dietary recall, on brachial and central

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Table 3 Estimated marginal means and standard errors for the cardiovascular variables stratified by fruit juice consumption with the additional adjustment for LDL and HDL cholesterol. Frequency of fruit juice consumption

ANCOVA

Rarely

F

Occasionally

Daily

p

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Brachial pressures Systolic BP 124.05 (0.65) 124.00 (0.79) 125.64 (1.16) 0.80 0.451 Diastolic BP 76.69 (0.32) 76.72 (0.39) 75.90 (0.58) 0.80 0.451 Pulse pressure 47.36 (0.97) 47.28 (1.18) 49.74 (1.75) 0.80 0.451 Central pressures Systolic BP 114.55 (0.55) 113.41 (0.68)** 117.33 (1.00) 5.38 0.006 Diastolic BP 77.58 (0.35) 77.26 (0.43) 76.60 (0.64) 0.86 0.425 Pulse pressure 36.97 (0.77) 36.15 (0.94)* 40.73 (1.39) 3.93 0.022 AP 9.83 (0.44)* 9.75 (0.53)** 12.59 (0.79) 5.30 0.006 AIx 26.14 (0.91) 26.54 (1.11) 30.37 (1.65) 2.54 0.083 PPA 1.29 (0.01) 1.31 (0.02)* 1.24 (0.02) 3.84 0.024

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Note: BP = blood pressure, AP = augmentation pressure, AIx = augmentation index, PPA = pulse pressure amplification. Group is significantly different to daily intake group at *p < 0.05 or **p < 0.001. All ANCOVA models are adjusted for age, gender, height, weight, mean arterial pressure, heart rate, treatment for lipids, treatment for hypertension, LDL cholesterol and HDL cholesterol.

BP. More frequent consumption of fruit juice was associated with higher central systolic BP, central pulse pressure as well as indirect measures of aortic stiffness and wave reflection. Interestingly, LDL cholesterol was higher and HDL cholesterol was lower in those who consumed fruit juice daily as compared to rarely. However, associations between fruit juice consumption and central BP mostly remained significant when controlling for lipoproteins in statistical models. To our knowledge, the association between habitual fruit juice consumption and central BP has not been investigated. The present findings suggest that the daily use of fruit juice may increase central BPs, which are known to be associated with cardiovascular disease risk (Vlachopoulos et al., 2010), silent cerebrovascular injury (Mitchell et al., 2011) and cognitive impairment (Pase et al., 2013). These findings are important because there is a common perception that fruit juice is healthy (Kim & House, 2014). Although fruit juices may contain essential vitamins (Ruxton et al., 2006), they commonly contain high amounts of sugar with negligible amounts of fibre. Thus, frequent fruit juice consumption may be contributing to excessive sugar intake (Huth et al., 2013), typical of the Western population, exacerbating the prevalence of hypertension and CVD (Johnson et al., 2007). Higher total intake of sugar sweetened beverages has been associated with higher systolic and diastolic BP in the INTERMAP study (Brown et al., 2011). Higher fructose consumption was also directly associated with higher BP. When focusing specifically on fruit juice, a follow-up paper from the same study found that brachial BP did not differ according to the frequency of fruit juice consumption (Griep et al., 2013). However, this same paper also reported no overall associations between raw fruit consumption and BP. This is in contrast to numerous studies which have shown that raw fruit and vegetable consumption is associated with lower BP (Ascherio et al., 1992, 1996; Miura et al., 2004) as well as a reduced risk of heart disease (Oude Griep et al., 2010) and stroke (Oude Griep et al., 2011), of which high BP is a major risk factor. Thus, as compared to raw fruit, the consumption of fruit juice may have different effects on BP. This requires future investigation as does the question of whether fruit juice consumption differentially affects BP as compared to other sugar sweetened beverages. Consistent with a previous observation (Griep et al., 2013), brachial BP did not differ according to frequency of fruit juice consumption. The present results further underscore the sensitivity of central BPs to dietary factors. These results should continue to encourage researchers to implement central BP in clinical trials and large observational studies dealing with nutrition factors and interventions. Future studies could also investigate the association of fruit juice consumption with carotid–femoral PWV, the goldstandard non-invasive measure of aortic stiffness (Laurent et al., 2006), and an independent predictor of CVD (Vlachopoulos, Aznaouridis, & Stefanadis, 2010) and related disorders such as stroke (Laurent et al., 2003) and cognitive impairment (Pase et al., 2012). There are two main limitations to the present study, the first being the small sample size and the second being the observational nature of the study design, which precludes us from drawing a causal link between increased fruit juice consumption and the development of high BP. A further limitation was that we were unable to calculate and therefore co-vary for total energy intake or total calories in our statistical models. With respect to our analyses, we grouped fruit juice consumption into categories of rare, occasional and daily. Different methods for creating categories of fruit juice consumption may produce different results. In light of these shortcomings, this study was designed to be hypothesis generating and it is hoped that the results will encourage other researchers to investigate the association between fruit juice consumption and BP in large epidemiological studies as well as in randomized, controlled trials of substantial duration. It must also be noted that not all juices are

Please cite this article in press as: Matthew P. Pase, Natalie Grima, Robyn Cockerell, Andrew Pipingas, Habitual intake of fruit juice predicts central blood pressure, Appetite (2014), doi: 10.1016/j.appet.2014.09.019

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equivalent as the amount of total sugar, fibre and vitamins are likely to differ between products. When limiting fruit juice consumption it will be important for individuals to obtain adequate vitamin/ mineral uptake from other dietary sources, such as whole fruits. Conclusions The primary prevention of hypertension can be improved by uncovering modifiable predisposing factors relating to diet and lifestyle. The current investigation showed that the daily versus rare or occasional consumption of fruit juice was associated with higher central BP, central pressure augmentation and PPA. These results may be due to the high sugar content of fruit juice. Given that high central BPs are associated with an increased risk of CVD and target organ damage, larger epidemiological studies and ultimately randomized controlled trials are needed to confirm the present findings.

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Please cite this article in press as: Matthew P. Pase, Natalie Grima, Robyn Cockerell, Andrew Pipingas, Habitual intake of fruit juice predicts central blood pressure, Appetite (2014), doi: 10.1016/j.appet.2014.09.019

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