Changes in Consumption of Sugary Beverages and Artificially Sweetened Beverages and Subsequent Risk of Type 2 Diabetes: Results From Three Large Prospective U.S. Cohorts of Women and Men

Abstract

Objective: We evaluated the associations of long-term changes in consumption of sugary beverages (including sugar-sweetened beverages and 100% fruit juices) and artificially sweetened beverages (ASBs) with subsequent risk of type 2 diabetes.

Research design and methods: We followed up 76,531 women in the Nurses' Health Study (1986-2012), 81,597 women in the Nurses' Health Study II (1991-2013), and 34,224 men in the Health Professionals' Follow-up Study (1986-2012). Changes in beverage consumption (in 8-ounce servings/day) were calculated from food frequency questionnaires administered every 4 years. Multivariable Cox proportional regression models were used to calculate hazard ratios for diabetes associated with changes in beverage consumption. Results of the three cohorts were pooled using an inverse variance-weighted, fixed-effect meta-analysis.

Results: During 2,783,210 person-years of follow-up, we documented 11,906 incident cases of type 2 diabetes. After adjustment for BMI and initial and changes in diet and lifestyle covariates, increasing total sugary beverage intake (including both sugar-sweetened beverages and 100% fruit juices) by >0.50 serving/day over a 4-year period was associated with a 16% (95% CI 1%, 34%) higher diabetes risk in the subsequent 4 years. Increasing ASB consumption by >0.50 serving/day was associated with 18% (2%, 36%) higher diabetes risk. Replacing one daily serving of sugary beverage with water, coffee, or tea, but not ASB, was associated with a 2-10% lower diabetes risk.

Conclusions: Increasing consumption of sugary beverages or ASBs was associated with a higher risk of type 2 diabetes, albeit the latter association may be affected by reverse causation and surveillance bias.

Figure 1

Pooled HRs (95% CIs) for type 2 diabetes according to updated 4-year changes in intakes of sugary beverages (A) and ASBs (B). The vertical bars represent consumption 4 years later: black bars, <1 serving/week (w); white bars, ≥1 serving/week to <1 serving/day (d); and gray bars, ≥1 serving/day. One beverage serving is 8 ounces. Cox proportional hazards models stratified by calendar year and adjusted for age, race (white or nonwhite), family history of diabetes (yes/no), physical examination during the 4-year cycle (yes/no), menopausal status and postmenopausal hormone use (premenopausal, postmenopausal + current use, postmenopausal + past use, postmenopausal + never use, or missing indicator), oral contraceptive use (never, current, past, or missing indicator), smoking status (never to never, never to current, past to past, past to current, current to past, current to current, or missing indicator), initial and change in physical activity level (MET-h/week, quintiles), initial and change in alcohol consumption (g/day, quintiles), initial and change in AHEI score (calculated without the alcohol and sugary beverage components, quintiles), initial and change in intakes of coffee, tea, milk, and water (quintiles or tertiles), initial and change in intakes of ASBs (for A) or sugary beverages (for B), initial BMI (<21.0, 21.0–24.9, 25.0–29.9, 30.0–31.9, ≥32.0 kg/m²), and initial calorie intake (quintiles). Results of the three cohorts were pooled using an inverse variance–weighted, fixed-effect meta-analysis.

Figure 2

Pooled HRs (95% CIs) for type 2 diabetes associated with increasing consumption of a beverage and concomitantly decreasing consumption of sugary beverages or ASB by one serving (8 ounces) per day. Cox proportional hazards models including all beverages simultaneously (initial and change, both continuous, in servings/day), adjusted for race (white or nonwhite), family history of diabetes (yes/no), physical examination during the 4-year cycle (yes/no), menopausal status and postmenopausal hormone use (premenopausal, postmenopausal + current use, postmenopausal + past use, postmenopausal + never use, or missing indicator), oral contraceptive use (never, current, past, or missing indicator), smoking status (never to never, never to current, past to past, past to current, current to past, current to current, or missing indicator), initial and change in physical activity level (MET-h/week, quintiles), alcohol consumption (g/day, quintiles), and AHEI score (calculated without the alcohol and sugary beverage components, quintiles), initial calorie intake (quintiles), and initial BMI (<21.0, 21.0–24.9, 25.0–29.9, 30.0–31.9, >32.0 kg/m²). Results of the three cohorts were pooled using an inverse variance–weighted, fixed-effect meta-analysis. *P for heterogeneity <0.05. m.-f., milk-fat.