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Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction

BMJ 2015; 351 doi: (Published 21 July 2015) Cite this as: BMJ 2015;351:h3576
  1. Fumiaki Imamura, senior investigator scientist1,
  2. Laura O’Connor, career development fellow1,
  3. Zheng Ye, investigator scientist1,
  4. Jaakko Mursu, research fellow2,
  5. Yasuaki Hayashino, vice director3, adjunct lecturer434,
  6. Shilpa N Bhupathiraju, research associate5,
  7. Nita G Forouhi, group leader1
  1. 1Medical Research Council Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge, CB2 0QQ, UK
  2. 2Institute of Public Health and Clinical Nutrition, University of Eastern Finland, Kuopio, Finland
  3. 3Department of Endocrinology, Tenri Hospital, Tenri City, Nara, Japan
  4. 4Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Sakyo-ku, Kyoto, Japan
  5. 5Department of Nutrition, Harvard T H Chan School of Public Health, Boston, MA, USA
  1. Correspondence to: F Imamura fumiaki.imamura{at}
  • Accepted 19 June 2015


Objectives To examine the prospective associations between consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice with type 2 diabetes before and after adjustment for adiposity, and to estimate the population attributable fraction for type 2 diabetes from consumption of sugar sweetened beverages in the United States and United Kingdom.

Design Systematic review and meta-analysis.

Data sources and eligibility PubMed, Embase, Ovid, and Web of Knowledge for prospective studies of adults without diabetes, published until February 2014. The population attributable fraction was estimated in national surveys in the USA, 2009-10 (n=4729 representing 189.1 million adults without diabetes) and the UK, 2008-12 (n=1932 representing 44.7 million).

Synthesis methods Random effects meta-analysis and survey analysis for population attributable fraction associated with consumption of sugar sweetened beverages.

Results Prespecified information was extracted from 17 cohorts (38 253 cases/10 126 754 person years). Higher consumption of sugar sweetened beverages was associated with a greater incidence of type 2 diabetes, by 18% per one serving/day (95% confidence interval 9% to 28%, I2 for heterogeneity=89%) and 13% (6% to 21%, I2=79%) before and after adjustment for adiposity; for artificially sweetened beverages, 25% (18% to 33%, I2=70%) and 8% (2% to 15%, I2=64%); and for fruit juice, 5% (−1% to 11%, I2=58%) and 7% (1% to 14%, I2=51%). Potential sources of heterogeneity or bias were not evident for sugar sweetened beverages. For artificially sweetened beverages, publication bias and residual confounding were indicated. For fruit juice the finding was non-significant in studies ascertaining type 2 diabetes objectively (P for heterogeneity=0.008). Under specified assumptions for population attributable fraction, of 20.9 million events of type 2 diabetes predicted to occur over 10 years in the USA (absolute event rate 11.0%), 1.8 million would be attributable to consumption of sugar sweetened beverages (population attributable fraction 8.7%, 95% confidence interval 3.9% to 12.9%); and of 2.6 million events in the UK (absolute event rate 5.8%), 79 000 would be attributable to consumption of sugar sweetened beverages (population attributable fraction 3.6%, 1.7% to 5.6%).

Conclusions Habitual consumption of sugar sweetened beverages was associated with a greater incidence of type 2 diabetes, independently of adiposity. Although artificially sweetened beverages and fruit juice also showd positive associations with incidence of type 2 diabetes, the findings were likely to involve bias. None the less, both artificially sweetened beverages and fruit juice were unlikely to be healthy alternatives to sugar sweetened beverages for the prevention of type 2 diabetes. Under assumption of causality, consumption of sugar sweetened beverages over years may be related to a substantial number of cases of new onset diabetes.


  • The following contributors provided additional information: Emilie Rossignol, Guy Fagherazzi, Françoise Clavel-Chapelon, and Beverley Balkau, Center for Research in Epidemiology and Population Health, Villejuif Cedex, France; Tomonori Okamura, Department of Preventive Medicine and Public Health, Keio University School of Medicine, Tokyo, Japan, and Hirotsugu Ueshima, Department of Health Science and Center for Epidemiologic Research in Asia; Sari Voutilainen, Institute of Public Health and Clinical Nutrition, Kuopio, Finland; Frank B Hu, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA; Manabu Sakurai, Department of Epidemiology and Public Health, Kanazawa Medical University, Uchinada, Ishikawa, Japan; Paul F Jacques, Nicola M McKeown, and Ma Jiantao, Human Nutrition Research Center on Aging, Tufts University, Boston, Massachusetts, USA.

  • Contributors: FI and NGF conceived the study. FI, LO’C, YZ, and NGF designed the study. FI, LO’C, and YZ undertook the literature search and extracted data. FI, JM, YH, and SNB did data analysis. FI, LO’C, YZ, and NGF interpreted data. FI developed the first draft. FI as guarantor accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish. All authors provided critical comments and approved the final version. The sponsor of the study had no role in design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.

  • Funding: This study was funded by the Medical Research Council Epidemiology Unit Core Support (MC_UU_12015/5). SNB was supported by an American Heart Association postdoctoral fellowship grant (13POST14370012).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not required.

  • Data sharing: A protocol and data for tables and figures are available on request.

  • Transparency: The guarantor (FI) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained as post hoc analysis. Data sharing is available from the corresponding author.

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