Beverage Choices and Their Effects on Risk of Developing Diabetes 

Beverage choices and diabetes risk: how much can one drink matter? Quite a bit, as it turns out. 

Diet and lifestyle changes are essential topics when counseling a patient with or without diabetes. There is strong evidence to support the relationship between sweetened beverages and type 2 diabetes. Many consider 100% fruit juices a healthy alternative to drinks with added sugar, despite having similar amounts of sugar. Despite this belief, there is evidence that fruit drinks are associated with an increased risk of developing diabetes. This study examined results from the Nurses’ Health Study (NHS), NHS II, and the Health Professionals’ Follow-up Study (HPFS) that included a look at the participants’ diet every four years, to assess the relationship of beverage choices and diabetes.  

The study sought to estimate the effect of replacing sugary beverages with artificially sweetened or other drinks, such as coffee, water, or tea, by examining the resultant risk of diabetes. The NHS is a prospective cohort study of 121,701 female nurses in the U.S. aged 30-55 at inception in 1976. The NHS II and HPFS are both prospective cohort studies that followed 116,430 female nurses in the U.S. aged 25-42 at the beginning in 1989 and 51,529 male U.S. health professionals aged 40-75 at starting in 1986, respectively. In all three, the diet was assessed every four years, with lifestyle and new health conditions assessed every two. This study used 1990 as a baseline for NHS and HPFS and 1995 as a baseline for NHS II to evaluate changes in beverage consumption. Participants were excluded if they had diabetes, cancer, or cardiovascular disease at baseline. After exclusions, the study included a total of 192,352 people. The primary endpoint was the analysis of the incidence of type 2 diabetes. The participants’ beverage habits were updated every four years, which was used to estimate the risk of diabetes during the next four years.  

This study covered over 2.7 million person-years and showed 11,906 incidences of type 2 diabetes. During the first four-year period, those who had an increase of sugary beverages of >0.5 servings per day were associated with a 16% higher risk (95% CI 1%, 34%) of diabetes than those who had a stable consumption. Increasing the use of sugar-sweetened beverages or fruit juices by >0.5 servings per day showed a higher risk of diabetes: 9% (95% CI 3%, 17%) and 15% (95% CI 7%, 23%), respectively, while increasing artificially sweetened beverages by that amount showed an 18% (95% CI 7% 36%) higher risk in developing diabetes in the next four-year period. Subsequent sensitivity analysis did not show a significant change in the main findings after being adjusted for differences in calorie intake and/or changes in body weight. Individuals who increased consumption from <1 serving per week to ≥1 meal per day of sugary beverages had an increased risk of diabetes over the next four years (HR 1.15, 95% CI 0.98, 1.35). Participants whose consumption of sugary drinks decreased from ≥1 serving per day to <1 per week had a 9% diabetes risk (95% CI -5, 25%). Those who continued to have ≥one serving per day had a 23% (95% CI 15%, 33%) higher risk of developing diabetes. Any increase in consumption of artificially sweetened beverages was shown to have a higher risk of diabetes when compared to those who had <1 serving per week. Replacing one meal of sugary drinks per day with an artificially sweetened beverage was not associated with diabetes risk in the next four years compared to the reference group, but replacing one serving with water, coffee, tea, or reduced-fat milk resulted in a 2-10% decreased risk of diabetes.  

This study adds to the understanding that drinks with sugar added to them are unhealthy. The analysis showed an increased risk of diabetes with increased consumption of sugary and artificially sweetened beverages. Increased use of 100% fruit juice with no sugar added also resulted in an increased risk of developing diabetes. The authors suggest this may be because sugary beverages provide lower satiety than solid food with the same calorie content and may result in increased consumption of overall calories. Participants who reduced their sweet beverage intake to <1 serving per week had the same risk of developing diabetes as those who maintained <1 serving per week over the same four-year period. This highlights the importance of dietary changes, even before a diabetes diagnosis. While increased consumption of artificial beverages was associated with an increased risk of diabetes, the authors caution that this may be due to surveillance bias or reverse causation. Even then, they recommend against artificially sweetened beverages as a substitute for sugary drinks. Instead, they recommend water, tea, or coffee.    

Practice Pearls: 

• Replacing a sugary beverage with water, coffee, or tea resulted in a 2-10% decreased risk of diabetes. These results were not seen when an artificially sweetened beverage was used. 
• Increasing consumption of any sugary beverage (including 100% fruit juice) results in an increase in the risk of diabetes by 16-18%. 
• Participants who decreased their intake of sugary beverages to <1 serving per week had a similar risk of developing diabetes as those who consistently consumed <1 sweet drink per week. 

Drouin-Chartier, Jean-Philippe, et al. “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.” Diabetes Care, American Diabetes Association, 1 Dec. 2019, care.diabetesjournals.org/content/42/12/2181. 

George McConnell, PharmD. Candidate, LECOM School of Pharmacy 

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