Guy Fagherazzi, PhD

Inserm U1018 team 9

“Nutrition, Hormones and Women’s health”

Villejuif, FRANCE

Consumption of artificially and sugar

sweetened beverages and risk of type 2

diabetes in the E3N cohort

Article publié en janvier 2013

Consumption of artificially and sugar sweetened beverages and

incident type 2 diabetes in the E3N-EPIC cohort.

Diabetes

• More than 3 millions of diabetic in France, 347 millions globally

• 90% are diagnosed with type 2 diabetes

• Diabetes is a leading cause of blindness, amputation and kidney failure.

• Type 2 diabetes can be prevented

Sugar sweetened beverages (SSB)

• High consumption of SSB is associated with an increased

risk of:

– T2D,

– Weight gain,

– Obesity,

– Metabolic Syndrome,

– CHD,

– High blood pressure…

• Biological mechanisms

– No reduction of energy intake after consumption of SSB

– A rapid spike in blood glucose and insulin levels - insulin resistance

over time

What is known (1/2)

What is known (2/2)

Artificially sweetened beverages (ASB)

• Artificially sweetened beverages (ASB) and T2D

• Most of the studies failed to find an association, however a few

concluded to an increased risk of T2D

• No clear biological mechanisms

– Reverse causation?

– Preference for sweets and an appetite enhancer?

– Aspartame might induce a 30mn postprandial increase in insulin

levels equivalent to sucrose

Anton et al. 2012 Appetite

E3N-EPIC cohort

• E3N is the French part of the EPIC

cohort

• E3N: ”Etude Epidémiologique auprès de

femmes de l’Education Nationale”

• Prospective cohort 98,995 women aged

between 40 and 65 were recruited in

1990

• Main objective: To study risk factors of

women’s main chronic diseases (cancer,

diabetes, cardiovascular diseases...)

• Self-administered questionnaires sent

every 2 or 3 years

• 1993: diet-history questionnaire

– Sugar sweetened beverages

– Artificially sweetened beverages

– Pure-fruit juice

Diet-history questionnaire

• Asked in 1993: 238-item food-frequency questionnaire

– Adapted to the French meal pattern

– Validated against 24h-recall questionnaires

– Both a quantitative and a qualitative part • Quantitative part: frequency & portion sizes per food group of food item

• Qualitative part: provide more information of items within one food group

7

Diet-history questionnaire

• Women were asked to report their food

consumption by meal

– Breakfast, Mid-morning snack, Appetizer,

Lunch, Afternoon snack, Appetizer,

Dinner, Night snack

• Women were helped with a photo

booklet to evaluate portion sizes

• Estimation of food consumption by

meal and by day + nutrients intakes

thanks to a food composition table

Meal Frequency Portion size

8

• Follow-up: 1993-2007

• N=66 118 women

• 1 369 incident validated diabetes cases

Baseline characteristics (in 1993) – Age = 52.6 years

– 18.8% of women with BMI>25kg/m²

– Only 1 on 6 woman drink either ASB or SSB

– Mean SSB consumption = 328.3 ml/week

– Mean ASB consumption= 567.7 ml/week

– Mean 100% fruit juice consumption = 686.7 ml/week

Study population

Statistical analyses

• Cox models

– Age as the time scale

– Model 1 adjusted for • years of education, smoking status

• physical activity

• hypertension, hypercholesterolemia

• use of hormone replacement therapy

• family history of diabetes

• alcohol intake, omega-3 fatty acid intake, carbohydrate intake, coffee, fruit and

vegetables, processed-meat consumption

• dietary pattern (Western or Mediterranean)

– Model 2 : model 1 + total energy intake

– Model 3 : model 2 + BMI (in kg/m²)

Influence of energy intake and BMI

Hazard ratios of T2D risk

Figure 1. Risk of type 2 diabetes according to categories of sugar and artificially sweetened

beverages and fruit juice consumptions. E3N cohort data (N=66 118).

0.5

1

1.5

2

2.5

SSB ASB

FJ

P<0.01 P<0.0001 P=0.2823

Spline regression models

+59%

Sensitivity analyses

• Reverse causation?

– Exclusion of the 5 first years of follow-up

– Similar results were obtained for the ≠ types of beverages :

• Increased risk of T2D for high consumption of SSB and ASB, no

association for FJ

• Associations mediated by BMI or energy intake?

– Increased risks slightly attenuated but still strongly significant

when adjusting for energy intake or BMI

• Interaction with BMI?

– Strength of the associations was attenuated with increase in

BMI categories. No more associations in obese women

– Limited statistical power

Strengths and limitations

• First prospective study on a French population

• Validated diabetes cases

• Validated dietary questionnaire

• Low consumption of SSB and ASB, low variability

• No updated information on consumption during the

follow-up

• No information on the type of SSB, ASB or 100%

fruit juice

– But in 1993, the ASB market was mainly composed of

products made with aspartame

Take-home message

• Reverse causation is unlikely to explain completely the association for

ASB

• More studies are needed on the impact of ASB on chronic conditions

– The relationship might be not causal

– ASB consumption may be associated with a risky behavior for T2D.

• We should be more cautious regarding the promotion of ASB as an

healthy alternative.

Both ASB and SSB were found to be directly

associated with an increased risk of T2D,

independent of BMI, in a population of French

women

Acknowledgments

• Alice Vilier

• Françoise Clavel-Chapelon

• Beverley Balkau

Thanks for your attention!