Relation of total sugars, fructose and sucrose with incident type 2 diabetes: a systematic review and meta-analysis of prospective cohort studies.

Marco Di Buono, John L Sievenpiper, David J A Jenkins, Cyril W C Kendall, Tauseef Khan, Joseph Beyene, Thomas M S Wolever, Lawrence A Leiter, Alexandra L Jenkins, Christine S Tsilas, Reem Tawfik, Vanessa Ha, Viranda H Jayalath, Adrian I Cozma, Arash Mirrahimi, Sonia Blanco Mejia, Russell J de Souza

Journal: CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne 2017;189(20):E711-E720

PMID: 28536126

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Plain Language Summary

Sugars, particularly fructose-containing sugars, have been implicated as an important driver in the rise in incidence of type 2 diabetes. The aim of this study was to determine the role of fructose-containing sugars independent of food form in the development of type 2 diabetes. This study is a systemic review and meta-analysis of prospective cohort studies. The study included 15 cohorts from 9 studies. Results indicate that intakes of total sugars and fructose were not associated with type 2 diabetes, whereas intake of sucrose was associated with an 11% decrease in type 2 diabetes. Authors conclude that in the absence of a clear signal for harm, sugars alone do not appear to explain the relation between sugar-sweetened beverages and type 2 diabetes.

Abstract

BACKGROUND

Sugar-sweetened beverages are associated with type 2 diabetes. To assess whether this association holds for the fructose-containing sugars they contain, we conducted a systematic review and meta-analysis of prospective cohort studies.

METHODS

We searched MEDLINE, Embase, CINAHL and the Cochrane Library (through June 2016). We included prospective cohort studies that assessed the relation of fructose-containing sugars with incident type 2 diabetes. Two independent reviewers extracted relevant data and assessed risk of bias. We pooled risk ratios (RRs) using random effects meta-analyses. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.

RESULTS

Fiffeen prospective cohort studies (251 261 unique participants, 16 416 cases) met the eligibility criteria, comparing the highest intake (median 137, 35.2 and 78 g/d) with the lowest intake (median 65, 9.7 and 25.8 g/d) of total sugars, fructose and sucrose, respectively. Although there was no association of total sugars (RR 0.91, 95% confidence interval [CI] 0.76-1.09) or fructose (RR 1.04, 95% CI 0.84-1.29) with type 2 diabetes, sucrose was associated with a decreased risk of type 2 diabetes (RR 0.89, 95% CI 0.80-0.98). Our confidence in the estimates was limited by evidence of serious inconsistency between studies for total sugars and fructose, and serious imprecision in the pooled estimates for all 3 sugar categories.

INTERPRETATION

Current evidence does not allow us to conclude that fructose-containing sugars independent of food form are associated with increased risk of type 2 diabetes. Further research is likely to affect our estimates.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01608620.

Address: Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask.; Toronto 3D Knowledge Synthesis and Clinical Trials Unit (Tsilas, de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Tawfik, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sievenpiper), Clinical Nutrition and Risk Factor Modification Centre, St. Michael's Hospital, Toronto, Ont.; Division of Food and Nutritional Sciences (Tsilas), Brescia University College at Western University, London, Ont.; Department of Nutritional Sciences (de Souza, Blanco Mejia, Mirrahimi, Cozma, Jayalath, Ha, Di Buono, A. Jenkins, Leiter, Wolever, Khan, Kendall, D. Jenkins, Sieven-piper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (de Souza, Ha, Beyene), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; School of Medicine (Mirrahimi), Faculty of Health Sciences, Queen's University, Kingston, Ont.; MD Program (Cozma, Jayalath), Faculty of Medicine University of Toronto, Toronto, Ont.; Department of Medicine (Leiter, Wolever, D. Jenkins, Sievenpiper), Faculty of Medicine, University of Toronto, Toronto, Ont.; Department of Psychology (Tawfik), Faculty of Arts, University of Waterloo, Waterloo, Ont.; American Heart Association (Di Buono), Dallas, Tex.; Division of Endocrinology and Metabolism (Leiter, Wolever, D. Jenkins, Sievenpiper); Li Ka Shing Knowledge Institute (Leiter, Wolever, D. Jenkins, Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Dalla Lana School of Public Health (Beyene), Faculty of Medicine, University of Toronto, Toronto, Ont.; College of Pharmacy and Nutrition (Kendall), University of Saskatchewan, Saskatoon, Sask. [email protected].

DOI: 10.1503/cmaj.160706