Type 2 diabetes

1. Prospective Association of Sweet Beverage Intake with Incident Type 2 Diabetes: The EPIC-Norfolk Study Laura O’Connor MRC Epidemiology Unit 25th June 2014, Institute of Public Health Away Day, 2014

2. Type 2 diabetes

3. Background – sweet beverages & T2D • RR 1.25 (1.10,1.42) • per serving (12 oz) • RR 1.18 (1.06,1.32) • per serving (12 oz)

4. Background – sweet beverages & T2D

5. Background – sweet beverages & T2D

6. Background – sweet beverages & T2D • Reducing SSB consumption is recommended • Insufficient evidence for appropriate alternatives to lower risk of diabetes

7. Aim • Associations of sweet beverage intake with T2D: • How substituting alternative beverages for sweet beverages affect the incidence of T2D

8. Methods Study design & participants • EPIC Norfolk Study • 25639 UK adults aged 40-79 at baseline Outcome – incident T2D • Incident cases ascertained until 31st July 2006 • Medical record linkage • 847 cases • 10.8 years of follow-up

9. Methods – Exposure: sweet beverage intake • Detailed prospective 7-day food diary • Per standard serving • 4 intake categories: non-consumers & consumers split by tertile 336 g/d 280 g/d 150 g/d

10. Methods – Statistical analysis • Cox proportional hazards regression for each sweet beverage type: per serving and by intake category • Substitution • non-sugar sweetened beverages for sweet beverages • per serving

11. Results – baseline characteristics

12. Results

13. Results

14. Results – Substitution, non-sugar sweetened beverage in place of a sweet beverage HR (95%CI) Most adjusted model including BMI and waist circumference

15. Results – Substitution, non-sugar sweetened beverage in place of a sweet beverage HR (95%CI) Most adjusted model including BMI and waist circumference

16. Results – Substitution, non-sugar sweetened beverage in place of a sweet beverage HR (95%CI) Most adjusted model including BMI and waist circumference

17. Results – Substitution, non-sugar sweetened beverage in place of a sweet beverage HR (95%CI) Most adjusted model including BMI and waist circumference

18. Results – Substitution, non-sugar sweetened beverage in place of a sweet beverage HR (95%CI) Most adjusted model including BMI and waist circumference

19. Results – Substitution, non-sugar sweetened beverage in place of a sweet beverage HR (95%CI) Most adjusted model including BMI and waist circumference

20. Summary • Soft drinks and sweetened milk beverage intake was associated with higher T2D risk,independent of adiposity • Sweetened tea/coffee, ASB and fruit juice was not associated • Consuming ASB in place of soft drinks and sweetened milk was not associated with T2D • Consuming drinking water or unsweetened tea & coffee in place of any SSB was inversely associated with T2D

21. Population impact of sweet beverage intake on T2D • % Population Attributable Fraction (PAF) of T2D incidence attributable to high % total energy from all sweet beverages • Assuming causality • 3 scenarios

22. Strengths and Limitations Strengths • Prospective detailed food diary data • examine individual beverage types • inclusion of beverages not previously examined • Incident T2D ascertained/verified using medical record linkage Limitations • Did not account for change in sweet beverage intake • Reporting bias • Residual confounding

23. Conclusion Consumption of soft drinks and sweetened milk beverages was associated with higher T2D risk Promoting drinking water or unsweetened tea/coffee in place of SSB may help curb the escalating diabetes epidemic 3 to 15 % of incident diabetes cases might be prevented if consumers of sweet beverages reduced intakes to below a range of 10 and 2 %TE

24. Acknowledgements Prospective Associations of Sweet Beverage Intake with Incident Type 2 Diabetes and Effects of Substitutions with Non-Sugar Sweetened Alternatives: The European Prospective Investigation into Cancer and Nutrition Norfolk Study, UK Laura O’Connor, PhD; Fumiaki Imamura, MS, PhD; Marleen AH Lentjes, MSc; Kay-Tee Khaw, FMedSci; Nicholas J Wareham, PhD, FRCP; Nita G Forouhi, PhD FFPHM With thanks to: Amit Bhaniani & Robert Luben Funding: The EPIC Norfolk Study is supported by programme grants from the Medical Research Council UK and Cancer Research UK

25. Thank you

26. Sensitivity analyses Adjusting for plasma vitamin C as an objective marker of dietary quality fibre intake as a marker of dietary quality non-sweet beverage energy in place of total energy Excluding those with prevalent chronic disease (n=2332) those with self-reported hypertension or hypercholesterolaemia (n=4943) those with incomplete food diary records (<7 days) (n=2219) the top 1% of consumers for each sweet beverage separately and simultaneously Including those originally excluded for having missing covariate data (n=591) Adjusting for plasma vitamin C, strengthened the association of fruit juice from HR (95%CI): 1.04 (0.92, 1.18) to 1.22 (1.07, 1.41)

27. Potential Mechanisms SSB risk of T2D Via effects on adiposity liquid calories are not fully compensated for, promoting weight-gain Independently via glycaemic effects of consuming large amounts of rapidly absorbable sugars metabolic effects of fructose Tea/coffee decrease risk of T2D Tea catechins inhibit carbohydrate digestive enzymes Black & green tea increase insulin sensitivity Green tea prevents damage to pancreatic β cells Coffee? Antioxidant in vivo, chlorogenic acid may delay glucose absorption