Prospective Association of Sweet
Beverage Intake with Incident Type 2
Diabetes: The EPIC-Norfolk Study
Laura O’Connor
MRC Epidemiology Unit
25th June 2014, Institute of Public Health Away Day, 2014
Type 2 diabetes
Background – sweet beverages & T2D
positive association
Sugar sweetened
beverages (SSB)
Meta-analysis of 8 studies (cases=15043)
Other sugar
sweetened beverages
?
Artificially-sweetened
beverage (ASB)
null & positive associations – role of
confounding & reverse causality by
adiposity not clear
Fruit juice (100%)
null & positive associations – limited
evidence
EPIC-InterAct study (cases=11,684)
RR 1.25 (1.10,1.42)
per1.18
serving
(12 oz)
RR
(1.06,1.32)
per serving (12 oz)
Background – sweet beverages & T2D
positive association
Sugar sweetened
beverages (SSB)
Other sugar
sweetened beverages
Meta-analysis of 8 studies (cases=15043)
EPIC-InterAct study (cases=11,684)
?
Artificially-sweetened
beverage (ASB)
null & positive associations – role of
confounding & reverse causality by
adiposity not clear
Fruit juice (100%)
null & positive associations – limited
evidence
Background – sweet beverages & T2D
positive association
Sugar sweetened
beverages (SSB)
Other sugar
sweetened beverages
Meta-analysis of 8 studies (cases=15043)
EPIC-InterAct study (cases=11,684)
?
Artificially-sweetened
beverages (ASB)
null & positive associations – role of
confounding & reverse causality by
adiposity not clear
Fruit juice (100%)
null & positive associations – limited
evidence
Background – sweet beverages & T2D
positive association
Sugar sweetened
beverages (SSB)
Other sugar
sweetened beverages
Meta-analysis of 8 studies (cases=15043)
EPIC-InterAct study (cases=11,684)
?
Artificially-sweetened
beverages (ASB)
null & positive associations – role of
confounding & reverse causality by
adiposity not clear
Fruit juice (100%)
null & positive associations – limited
evidence
• Reducing SSB consumption is recommended
• Insufficient evidence for appropriate alternatives to lower
risk of diabetes
Aim
1. Associations of sweet beverage intake with T2D:
SSB
Soft drinks
Sweetened tea & coffee
Sweetened milk beverages
ASB
Fruit juice (100%)
2. How substituting alternative beverages for sweet
beverages affect the incidence of T2D
Methods
Study design & participants
• EPIC Norfolk Study
• 25639 UK adults aged 40-79 at baseline
Outcome – incident T2D
• Incident cases ascertained until 31st July 2006
• Medical record linkage
• 847 cases
• 10.8 years of follow-up
Methods – Exposure: sweet beverage intake
• Detailed prospective
7-day food diary
• Per standard serving
336 g/d
280 g/d
150 g/d
• 4 intake categories:
non-consumers &
consumers split by tertile
Methods – Statistical analysis
• Cox proportional hazards regression for each sweet beverage
type: per serving and by intake category
• Substitution
• non-sugar sweetened beverages for sweet beverages
• per serving
Results – baseline characteristics
broadly similar to total cohort
Soft drinks
Sweetened
tea & coffee
lower social class
“less healthy” diets
Sweetened
milk
beverages
lower social class
“less healthy” diets
ASB
Fruit juice
(100%)
younger, more women, more obese
more physically active, lower EI
higher social class
“healthier diets”
Results
Prospective association of sweet beverage intake & T2D, HR (95%CI)
per serving
Soft drinks
Adjusted model
+ BMI and waist circumference
Sweetened tea & coffee
Adjusted model
+ BMI and waist circumference
Sweetened milk beverages
Adjusted model
+ BMI and waist circumference
ASB
Adjusted model
+ BMI and waist circumference
Fruit juice
Adjusted model
+ BMI and waist circumference
336 g/d
1.21 (1.05, 1.39)
1.14 (1.01, 1.32)
280 g/d
0.98 (0.94, 1.02)
1.03 (0.99, 1.07)
280 g/d
1.22 (1.05, 1.43)
1.27 (1.09, 1.48)
336 g/d
1.22 (1.11, 1.33)
1.06 (0.93, 1.20)
150 g/d
1.01 (0.88, 1.15)
1.04 (0.92, 1.19)
Nonconsumers
Reference
group
High consumers
Tertile 3
Range: 142-3314 g/d
1.25 (1.05, 1.50)
1.18 (0.98, 1.41)
Range: 877-5096 g/d
0.95 (0.77, 1.16)
1.22 (0.99, 1.50)
Range: 211-2653 g/d
1.41 (1.16, 1.73)
1.49 (1.22, 1.81)
Range: 169-5848 g/d
1.65 (1.31, 2.07)
1.18 (0.94, 1.50)
Range: 123-1372 g/d
0.92 (0.75, 1.13)
0.98 (0.80, 1.21)
Adjusted for age, sex, social class, education level, family history of diabetes, physical activity level , smoking status, alcohol
consumption, season, mutual adjustment for intake of other sweet beverages, total energy intake
Results
Prospective association of sweet beverage intake & T2D, HR (95%CI)
per serving
Soft drinks
Adjusted model
+ BMI and waist circumference
Sweetened tea & coffee
Adjusted model
+ BMI and waist circumference
Sweetened milk beverages
Adjusted model
+ BMI and waist circumference
ASB
Adjusted model
+ BMI and waist circumference
Fruit juice
Adjusted model
+ BMI and waist circumference
336 g/d
1.21 (1.05, 1.39)
1.14 (1.01, 1.32)
280 g/d
0.98 (0.94, 1.02)
1.03 (0.99, 1.07)
280 g/d
1.22 (1.05, 1.43)
1.27 (1.09, 1.48)
336 g/d
1.22 (1.11, 1.33)
1.06 (0.93, 1.20)
150 g/d
1.01 (0.88, 1.15)
1.04 (0.92, 1.19)
Nonconsumers
Reference
group
High consumers
Tertile 3
Range: 142-3314 g/d
1.25 (1.05, 1.50)
1.18 (0.98, 1.41)
Range: 877-5096 g/d
0.95 (0.77, 1.16)
1.22 (0.99, 1.50)
Range: 211-2653 g/d
1.41 (1.16, 1.73)
1.49 (1.22, 1.81)
Range: 169-5848 g/d
1.65 (1.31, 2.07)
1.18 (0.94, 1.50)
Range: 123-1372 g/d
0.92 (0.75, 1.13)
0.98 (0.80, 1.21)
Adjusted for age, sex, social class, education level, family history of diabetes, physical activity level , smoking status, alcohol
consumption, season, mutual adjustment for intake of other sweet beverages, total energy intake
HR (95%CI)
Results – Substitution, non-sugar sweetened
beverage in place of a sweet beverage
Most adjusted model including
BMI and waist circumference
HR (95%CI)
Results – Substitution, non-sugar sweetened
beverage in place of a sweet beverage
Most adjusted model including
BMI and waist circumference
HR (95%CI)
Results – Substitution, non-sugar sweetened
beverage in place of a sweet beverage
Most adjusted model including
BMI and waist circumference
HR (95%CI)
Results – Substitution, non-sugar sweetened
beverage in place of a sweet beverage
Most adjusted model including
BMI and waist circumference
HR (95%CI)
Results – Substitution, non-sugar sweetened
beverage in place of a sweet beverage
Most adjusted model including
BMI and waist circumference
HR (95%CI)
Results – Substitution, non-sugar sweetened
beverage in place of a sweet beverage
Most adjusted model including
BMI and waist circumference
Summary
• Soft drinks and sweetened milk beverage intake was
associated with higher T2D risk, independent of adiposity
• Sweetened tea/coffee, ASB and fruit juice was not
associated
• Consuming ASB in place of soft drinks and sweetened
milk was not associated with T2D
• Consuming drinking water or unsweetened tea & coffee
in place of any SSB was inversely associated with T2D
Population impact of sweet beverage
intake on T2D
• % Population Attributable Fraction (PAF) of T2D incidence
attributable to high % total energy from all sweet
beverages
• Assuming causality
• 3 scenarios
Contribution of sweet
beverages
PAF (95% CI)
<10% total energy
3 (1 to 7) %
<5% total energy
7 (1 to 13) %
<2% total energy
15 (3 to 25) %
Strengths and Limitations
Strengths
• Prospective detailed food diary data
• examine individual beverage types
• inclusion of beverages not previously examined
• Incident T2D ascertained/verified using medical record linkage
Limitations
• Did not account for change in sweet beverage intake
• Reporting bias
• Residual confounding
Conclusion
Consumption of soft drinks and sweetened milk beverages
was associated with higher T2D risk
Promoting drinking water or unsweetened tea/coffee in
place of SSB may help curb the escalating diabetes
epidemic
3 to 15 % of incident diabetes cases might be prevented if
consumers of sweet beverages reduced intakes to below a
range of 10 and 2 %TE
Acknowledgements
Prospective Associations of Sweet Beverage Intake with Incident Type 2
Diabetes and Effects of Substitutions with Non-Sugar Sweetened
Alternatives: The European Prospective Investigation into Cancer and
Nutrition Norfolk Study, UK
Laura O’Connor, PhD; Fumiaki Imamura, MS, PhD; Marleen AH Lentjes, MSc;
Kay-Tee Khaw, FMedSci; Nicholas J Wareham, PhD, FRCP; Nita G Forouhi, PhD
FFPHM
With thanks to: Amit Bhaniani & Robert Luben
Funding: The EPIC Norfolk Study is supported by programme grants
from the Medical Research Council UK and Cancer Research UK
Thank you
Sensitivity analyses
• Adjusting for
• plasma vitamin C as an objective marker of dietary quality
• fibre intake as a marker of dietary quality
• non-sweet beverage energy in place of total energy
• Excluding
• those with prevalent chronic disease (n=2332)
• those with self-reported hypertension or hypercholesterolaemia
(n=4943)
• those with incomplete food diary records (<7 days) (n=2219)
• the top 1% of consumers for each sweet beverage separately
and simultaneously
• Including those originally excluded for having missing covariate data
(n=591)
Adjusting for plasma vitamin C, strengthened the
association of fruit juice from HR (95%CI): 1.04 (0.92, 1.18)
to 1.22 (1.07, 1.41)
Potential Mechanisms
SSB
risk of T2D
Via effects on adiposity
liquid calories are not fully compensated for, promoting
weightgain
Independently
via glycaemic effects of consuming large amounts of rapidly
absorbable sugars
metabolic effects of fructose
Tea/coffee
decrease risk of T2D
Tea catechins inhibit carbohydrate digestive enzymes
Black & green tea increase insulin sensitivity
Green tea prevents damage to pancreatic β cells
Coffee? Antioxidant in vivo, chlorogenic acid may delay glucose absorption