Healthy Beverage Choices May Lower Mortality Risk in Adults with Diabetes

Qi Sun, MD

Credit: Harvard T.H. Chan School of Public Health

Among an adult population with type 2 diabetes (T2D), a higher intake of sugar-sweetened beverages (SSBs) was associated with higher all-cause mortality and incidence of cardiovascular disease (CVD), according to new research.¹

However, replacing sugar-sweetened beverages with coffee, tea, plain water, or low-fat milk was statistically significantly associated with lower all-cause and CVD mortality among those with T2D, according to the investigative team, led by Qi Sun, MD, Harvard T.H. Chan School of Public Health.

“Overall, these results provide additional evidence that emphasizes the importance of beverage choice in maintaining overall health among adults with diabetes,” Sun and colleagues wrote.¹

Around 500 million adults globally had diabetes in 2021, with the number of cases expected to rise to over 700 million in the next two decades.Diet plays a role in the glycemic management of T2D, but current recommendations and guidelines for the general population may not be relevant to adult with diabetes. In particular, the investigative team highlighted the need to investigate the link between individual beverage consumption, such as SSBs and artificially sweetened beverages (ASBs), and CVD risk and mortality in T2D.

Sun and colleagues conducted a prospective study to examine the intake of specific beverage consumption after diagnosis and the change in consumption before and after diagnosis in relation to CVD risk and mortality in adults with T2D. They further estimated associations between substituting one beverage for another and CVD risk and mortality.

The analysis included health professionals with prevalent T2D at baseline from the Nurses’ Health Study (1980 - 2018) and the Health Professionals Follow-Up Study (1986 - 2018), as well as those with a diagnosis of incident T2D during follow-up until 2018. After excluding patients with type 1 diabetes, CVD, or cancer at baseline, a total of 11,399 participants of the Nurses’ Health Study and 4087 participants of the Health Professionals Follow-up Study were included in analysis. To analyze change in beverage consumption from before to after diagnosis, investigators excluded those with T2D at baseline or those with missing data, leaving 9252 women and 3519 men for the change analysis.

The intake of beverages was assessed using a validated food frequency questionnaire and updated every 2 to 4 years. Participants were asked how often they had consumed SSBs, ASBs, fruit juice, coffee, tea, low fat milk, full fat milk, or plain water of a prespecified portion size. The primary endpoint analyzed was all-cause mortality and secondary outcomes included CVD incidence and mortality.

Over an average of 18.5 years, a total of 7,638 (49.3%) deaths were recorded in the study. The analysis showed participants with the highest intake of SSBs (>1 serving a day) had a 20% increased risk of all-cause mortality (hazard ratio [HR], 1.20; 95% CI, 1.04 - 1.37) compared with participants with the lowest intake (<1 serving a month).

Contrastingly, the team found high intakes of certain beverages were associated with lower mortality: 26% lower mortality for coffee, 21% lower for tea, 23% lower for plain water, and 12% lower for low-fat milk. Each additional serving a day increment in SSBs was associated with 8% (95% CI, 2 - 14) higher all-cause mortality.

In the same period, investigators recorded a total of 3447 (22.3%) adults with incident CVD. Similar to all-cause mortality, a higher intake of SSBs was significant associated with a 25% higher risk of CVD (HR, 1.25; 95% CI, 1.03 - 1.51). Meanwhile, increased consumption of coffee and low fat milk was inversely associated with CVD incidence, at an 18% and 12% lower risk of CVD, respectively.

Investigators additionally found an increment in coffee consumption from before to after diabetes diagnosis was significantly associated with a lower risk of all-cause mortality. In comparison to those whose coffee intake did not change, individuals with increase coffee consumption had an 18% lower risk of all-cause mortality. A similar associated was noted for both tea (16% lower) and low-fat milk (12%).

Moreover, the analysis suggested replacing one serving/day of SSBs with ASBs was significantly associated with an 8% and 15% lower all-cause mortality and CVD mortality, respectively. Replacing one/serving a day of ASBs with coffee, tea, or plain water was also associated with lower all-cause mortality, according to the analysis.

In a linked editorial, Nita G Forouhi, University of Cambridge School of Clinical Medicine, suggested that the findings point to a lower consumption of SSBs as optimal for better health outcomes in adults with T2D.² She noted that while the observational findings cannot be considered cause and effect, large-scale, long-term randomized controlled interventions on beverage type and dose may not be practical.

“As previous research was conducted in general populations, the new study credibly extends our understanding of the health implications of different beverages to adults with T2D,” Forouhi wrote.²

Forouhi raised concerns about the generalizability of the study findings to other demographic groups, as the study cohort was predominantly white, as well as varying disease severities. She also questioned the impact of unexamined popular beverages and whether results differed for coronary heart disease and stroke risk.

“Future research should plug these gaps in understanding,” she wrote.² “Researchers could also use objective biomarkers to help overcome the limitations of subjective, potentially error prone and biased reporting of beverage consumption.”

References

1. Ma L, Hu Y, Alperet DJ, et al. Beverage consumption and mortality among adults with type 2 diabetes: prospective cohort study. BMJ. 2023;381:e073406. Published 2023 Apr 19. doi:10.1136/bmj-2022-073406
2. Forouhi NG. Beverages and health outcomes in adults with type 2 diabetes. BMJ. 2023;381:p841. Published 2023 Apr 19. doi:10.1136/bmj.p841
3. bmj_company. (2023, April 19). Swapping sugary drinks for coffee, tea or water linked to fewer deaths in adults with diabetes. EurekAlert! Retrieved April 20, 2023, from https://www.eurekalert.org/news-releases/986450