Consumption of Sweetened Beverages and Intakes of Fructose and Glucose Predict Type 2 Diabetes Occurrence

According to the American Diabetes Association’s guideline, a moderate amount of sugar can be incorporated in a healthy diet and sucrose and sucrose-containing food in diabetic individuals

need not be restricted because of a concern about aggravating hyperglycemia (1). However, different types of sugars may have variable metabolic affects on glycemia (2–4) and the role of different sugars in the development of type 2 diabetes is yet scarcely studied. Glucose and fructose are natural components of fruits and berries. In addition, a significant proportion of sucrose in sucrose-containing foods, especially beverages, is hydrolyzed into glucose and fructose before the product is consumed. Glucose has a glycemic index of 141 compared with white bread (5) and, accordingly, it has been observed that of sugars, glucose best predicted an increase in blood glucose level (6). Glucose intake predicted an increased risk of type 2 diabetes in a large-scale prospective study in 

American women (7), but the result was not confirmed in another prospective study (8). Fructose has been thought to be a safer form of sugar than sucrose due to a lower glycemic response after ingestion. In clin- ical studies, short-term fructose intake has either improved metabolic control or caused no changes (9,10). However, feeding studies in animals have suggested that fructose intake has a detrimental effect on body weight, plasma glucose, and insulin levels and insulin sensitivity, but the long-term effects of fructose intake in relation to insulin activity and sensitivity in human studies are less clear (11). In a few studies, diets high in fructose have led to reduced insulin sensitivity (12,13) or decreased plasma glucose levels (14,15). Dietary fructose intake was associated with the incidence of type 2 diabetes in a large-scale follow-up study in older women (7), but no significant association was observed in another large-scale cohort of women (8). Cross-sectional anal- ysis based on Nurses’ Health Studies I and II showed an associa- tion between fructose intake and plasma C-peptide concentration (16). Data on the long-term effects of different sugars on the risk of type 2 diabetes in healthy individuals are sparse and a major need exists for more research in this area, especially on the role of fructose (16). The association between intakes of different sugars and the incidence of type 2 diabetes was studied in a large nationwide cohort of Finns.

In this study, higher intakes of combined fructose and glucose predicted an increased risk of type 2 diabetes. The association persisted after adjustment for several potential confounding factors related to lifestyle, dietary patterns, and total sugar intake.

Therefore, it is possible that the association of glucose or fructose intake with the development of type 2 diabetes could beascribed to these monosaccharides per se or factors specifically related to their intake. The association was prominent only in

the highest quartile of the intake.

The result of this study is in line with the previous prospective analysis of the data from the Iowa Women’s Health Study, in which intakes of glucose and fructose were associated with increased risk of type 2 diabetes (7) and with cross-sectional analysis that showed an association between fructose intake and blood C-peptide level (16). However, no significant association was ob-

served in the prospective analysis of the data from the Women’s Health Study (8). A high correlation between glucose and fruc- tose intakes, however, makes it impossible to differentiate their associations with diabetes risk.

Another potential mechanism that may have mediated the effect of glucose or fructose is the low satiety of the liquid foods representing important sugar sources. It has been observed that an excess intake of sugar in liquid form is not compensated by the reduction in food and energy intake and therefore promotes weight gain (54–56). Accordingly, consumption of sweetened berry juice and soft drinks was associated with an increased diabetes risk in our data, which is consistent with recent findings on the consumption of sweetened beverages and fruit punches and diabetes incidence (57). A modest inverse association has been observed between su- crose intake and diabetes risk in previous studies (7,8). However, no significant association was observed between total sucrose

intake and diabetes risk in our study, but added sugar (sucrose) used as such suggested an inverse nonsignificant association with

the diabetes risk in our data.

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