Sugar-sweetened beverages linked with increased risk of premature death for people with type 2 diabetes
Key points:
- This is among the first large-scale studies to examine associations between beverage consumption, all-cause mortality, and cardiovascular disease mortality specifically among people living with type 2 diabetes
- Those with type 2 diabetes who regularly consumed sugar-sweetened beverages like soda or lemonade had a higher risk of developing cardiovascular disease and/or dying prematurely than those who regularly consumed beverages like coffee, tea, low-fat cow’s milk, and plain water
- Each additional daily serving of a SSB was associated with an 8% higher all-cause mortality among those with type 2 diabetes. Replacing one daily serving of a SSB with a healthier beverage was associated with up to an 18% lower risk of all-cause mortality
Boston, MA—High consumption of sugar-sweetened beverages (SSBs) was associated with an elevated risk of premature death and incidence of cardiovascular disease (CVD) among people with type 2 diabetes, according to a new study led by researchers at Harvard T.H. Chan School of Public Health. Drinking beverages like coffee, tea, low-fat cow’s milk, and plain water was associated with lower risk of dying prematurely.
The study looked specifically at consumption of different beverages among patients with type 2 diabetes. While many prior studies have linked beverage consumption and health outcomes such as cardiometabolic health, weight change, and mortality, those studies have primarily been among the general population.
“Beverages are an important component of our diet, and the quality can vary hugely,” said lead author Qi Sun, associate professor in the Departments of Nutrition and Epidemiology. “People living with diabetes may especially benefit from drinking healthy beverages—but data has been sparse. These findings help fill in that knowledge gap and may inform patients and their caregivers on diet and diabetes management.”
The study will be published online April 19, 2023 in The BMJ.
The researchers analyzed an average of 18.5 years of health data from 9,252 women participating in the Nurse’s Health Study and 3,519 men participating in the Health Professionals Follow-up Study, all of whom had been diagnosed with type 2 diabetes at baseline or at some point during the study. Every two to four years, the participants reported on how often they consumed SSBs (including sodas, fruit punch, and lemonade), artificially sweetened beverages (ASBs), fruit juice, coffee, tea, low-fat cow’s milk, full-fat cow’s milk, and plain water.
The findings showed higher all-cause mortality, and higher incidence of and mortality from CVD, among those who regularly consumed SSBs: Every additional daily serving of a SSB was associated with an 8% higher all-cause mortality. Inversely, all-cause mortality and incidence of and mortality from CVD decreased among those who regularly consumed healthier beverages such as coffee, tea, low-fat cow’s milk, and/or plain water. Replacing one daily serving of a SSB with one serving of coffee was associated with an 18% lower risk of all-cause mortality and a 20% lower risk of CVD mortality; tea with 16% and 24% lower risk; plain water with a 16% and 20% lower risk; and low-fat cow’s milk with a 12% and 19% lower risk. Drinking ASBs was also associated with healthier outcomes, but less so: Replacing one daily serving of a SSB with an ASB was associated with an 8% lower risk of all-cause mortality and a 15% lower risk in CVD mortality.
“People living with diabetes should be picky about how they keep themselves hydrated,” said Sun. “Switching from sugar-sweetened beverages to healthier beverages will bring health benefits.”
Other Harvard Chan School co-authors included Le Ma, Yang Hu, Derrick Alperet, Vasanti Malik, JoAnn Manson, Eric Rimm, and Frank Hu.
Funding for the study came from the National Institutes of Health grants UM1 CA186107, U01 CA167552, R01 HL034594, R01 HL035464, DK126698, DK120870, and DK119268.
“Beverage consumption and mortality among adults with type 2 diabetes: prospective cohort study,” Le Ma, Yang Hu, Derrick J. Alperet, Gang Liu, Vasanti Malik, JoAnn E. Manson, Eric B. Rimm, Frank B. Hu, Qi Sun, BMJ, online April 19, 2023, doi: 10.1136/bmj-2022-073406
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Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people’s lives—not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America’s oldest professional training program in public health.
JOURNAL
The BMJ
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
Not applicable
ARTICLE TITLE
Beverage consumption and mortality among adults with type 2 diabetes: prospective cohort study,”
ARTICLE PUBLICATION DATE
19-Apr-2023
Swapping sugary drinks for coffee, tea or water linked to fewer deaths in adults with diabetes
Findings highlight role of healthy beverage choices to manage risk, say researchers
Peer-Reviewed PublicationFor adults with type 2 diabetes, replacing sugary drinks with coffee, tea, or plain water is linked to lower rates of early death due to cardiovascular disease (CVD) and other causes, finds research published by The BMJ.
A greater increase in coffee and tea consumption from before to after a diabetes diagnosis was also associated with lower death rates. These findings highlight the potential role of healthy beverage choices in managing risk for adults with type 2 diabetes, say the authors.
In 2021, over 500 million adults worldwide had type 2 diabetes, which carries an increased risk of CVD and premature death, and this number is set to rise to 783 million by 2045.
Diet plays a key role in managing diabetes, but little is known about intake of specific types of beverages in relation to death and CVD among adults with type 2 diabetes.
To fill this knowledge gap, researchers drew on data for 15,486 adults (74% women; average age 61 years) with a diagnosis of type 2 diabetes who were part of the Nurses’ Health Study (1980-2018) and Health Professionals Follow-Up Study (1986-2018) in the United States.
Beverage consumption was assessed using a validated food questionnaire and updated every two to four years. This included sugar sweetened beverages (SSBs), artificially sweetened (low-calorie) beverages (ASBs), fruit juice, coffee, tea, low fat and full fat milk, and plain water.
During an average 18.5 years of follow-up, the researchers recorded 3,447 cases of CVD and 7,638 deaths.
After accounting for other lifestyle factors and medical history, they found that participants with the highest intake of SSBs (more than 1 serving a day) had a 20% increased risk of death from any cause compared with participants with the lowest intake (less than 1 serving a month).
In contrast, high intakes of certain beverages (up to 6 servings a day) were associated with lower mortality: 26% lower for coffee, 21% for tea, 23% for plain water, and 12% for low fat milk.
Similar associations were seen between the individual beverages and CVD rates and mortality. In particular, SSB intake was associated with a 25% higher risk of CVD and a 29% higher risk of CVD related mortality, whereas intake of coffee and low fat milk were associated with an 18% and 12% lower risk of CVD, respectively.
Compared with those who did not change their consumption of coffee in the period after a diabetes diagnosis, an 18% lower all cause mortality was seen in those who increased their consumption of coffee. A similar pattern for all cause mortality was also found for tea, and low fat milk.
Replacing SSBs with ASBs was also associated with lower all cause mortality and CVD mortality, and replacing SSBs, ASBs, fruit juice, or full fat milk with coffee, tea, or plain water was consistently associated with lower all cause mortality.
This is an observational study, so can’t establish cause, and the researchers acknowledge that individual beverage consumption may be linked to other dietary and lifestyle risk factors for CVD and mortality among adults with diabetes, and they can’t rule out the possibility that measurement errors or misclassification may have influenced the results.
However, this was a large study with a long follow-up period, high response rates, and detailed and repeated assessments of dietary and lifestyle variables before and after a diabetes diagnosis.
As such, they conclude: “Overall, these results provide additional evidence that emphasises the importance of beverage choices in maintaining overall health among adults with diabetes.” Further studies are warranted to replicate and further explore these important associations, they add.
This new study extends our understanding of the health implications of different beverages to adults with type 2 diabetes, says Nita Forouhi at the MRC Epidemiology Unit, University of Cambridge, in a linked editorial.
Questions remain, however, such as the effect of adding sugar to coffee or tea, and the impact of other popular drinks, like milkshakes, smoothies, and hot chocolate, she writes. It is also unclear whether the findings apply to different population groups as the study focused on predominantly white US health professionals.
Nevertheless, choice of beverage clearly matters, she says. The case for avoiding sugar sweetened beverages is compelling in the general population, and it is reasonable to shift the focus to drinks that are most likely to have positive health effects: coffee, tea, plain water, and low fat milk, she concludes.
JOURNAL
The BMJ
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Beverage consumption and mortality among adults with type 2 diabetes: prospective cohort study
ARTICLE PUBLICATION DATE
19-Apr-2023
COI STATEMENT
All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the National Institutes of Health (NIH) for the submitted work; JEM has been supported by grants from NIH. FBH has been supported by grants HL60712, HL118264, and DK112940 from NIH and received research support from the California Walnut Commission, honorariums for lectures from Metagenics and Standard Process, and honorariums from Diet Quality Photo Navigation, outside the submitted work; VM has received research support from Canada Research Chairs Program, Connaught New Researcher Award, University of Toronto, and The Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, received consulting fees from the World Health Organization Nutrition Guidance Expert Advisory Group, and has held a leadership role in Canadian Institutes of Health Research Advisory Board, Institute of Nutrition, Metabolism and Diabetes. No other relationships or activities that could appear to have influenced the submitted work
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