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. 2025 Apr;68(4):792-800.
doi: 10.1007/s00125-024-06351-w. Epub 2025 Jan 8.

Sugar-sweetened or artificially sweetened beverage consumption, physical activity and risk of type 2 diabetes in US adults

Lorena S Pacheco  1 , Deirdre K Tobias  2   3 , Danielle E Haslam  2   4 , Jean-Philippe Drouin-Chartier  5   6 , Yanping Li  2 , Shilpa N Bhupathiraju  2   4 , Walter C Willett  2   7 , David S Ludwig  2   8 , Cara B Ebbeling  8 , Frank B Hu  2   4   7 , Marta Guasch-Ferré  9   10   11
Affiliations

Sugar-sweetened or artificially sweetened beverage consumption, physical activity and risk of type 2 diabetes in US adults

Lorena S Pacheco et al. Diabetologia. 2025 Apr.

Abstract

Aims/hypothesis: A positive association between sugar-sweetened beverages (SSBs) and diabetes risk has been shown, with inconsistent evidence between artificially sweetened beverages (ASBs) and diabetes. Moreover, it is uncertain if physical activity can mitigate the negative effects of these beverages on diabetes development. Therefore, we aimed to evaluate the independent and joint associations between SSB or ASB consumption and physical activity on the risk of type 2 diabetes.

Methods: We followed 64,029 women in the Nurses' Health Study (1980-2016), 88,340 women in the Nurses' Health Study II (1991-2017) and 39,436 men in the Health Professionals Follow-up Study (1986-2016). SSB and ASB consumption was calculated from food-frequency questionnaires administered every 4 years, while physical activity data were collected biennially. A validated supplementary questionnaire on diabetes symptoms, diagnostic tests and treatment confirmed type 2 diabetes cases. Multivariable Cox proportional hazards regression models were used to calculate HRs and 95% CIs for developing type 2 diabetes.

Results: During 5,105,351 person-years of follow-up, we recorded 19,940 new cases of type 2 diabetes. Compared with those who never or rarely consumed SSBs or ASBs, those who consumed ≥2 servings/day had a 41% (HR 1.41 [95% CI 1.33, 1.50]) and 11% (HR 1.11 [95% CI 1.07, 1.16]) higher risk of type 2 diabetes, respectively. For participants meeting physical activity guidelines (≥7.5 metabolic equivalent of task [MET] h/week) and consuming ≥2 servings/week of SSBs or ASBs, the risk was 22% (HR 1.22 [95% CI 1.15, 1.29]) and 7% (HR 1.07 [95% CI 1.02, 1.12]) higher, respectively, compared with those who met physical activity guidelines and never or rarely (<1 serving/month) consumed these beverages. For participants meeting the physical activity guidelines and consuming 1-4 servings/month of SSBs, there was a 9% (HR 1.09 [95% CI 1.02, 1.15]) higher risk of type 2 diabetes. Compared with the reference group (those who met physical activity guidelines and consumed <1 SSB serving/month), adults who did not meet physical activity guidelines (<7.5 MET h/week) and who never or rarely (<1 serving/month) consumed SSBs, had 1-4 SSB servings/month, or had ≥2 SSB servings/week, the HRs (95% CIs) were 1.22 (1.13, 1.31), 1.28 (1.20, 1.37), and 1.51 (1.43, 1.61), respectively. Similarly, for ASB consumption, adults who did not meet physical activity guidelines and who never or rarely (<1 serving/month) consumed ASBs, had 1-4 servings/month, or had ≥2 servings/week, the HRs (95% CIs) were 1.21 (1.14, 1.28), 1.21 (1.13, 1.30), and 1.30 (1.23, 1.37) compared with the reference group (who met physical activity guidelines and consumed <1 ASB serving/month).

Conclusions/interpretation: Even when individuals were physically active, a higher consumption of SSBs or ASBs was associated with a higher risk of type 2 diabetes. Meeting physical activity guidelines reduced the impact of SSB and ASB consumption on diabetes risk, underscoring the need to promote physical activity as part of lifestyle modifications to lower diabetes incidence.

Keywords: Artificial sweetener; Beverages; Exercise; Incidence; Nutritional epidemiology; Observational study; Sucrose; Type 2 diabetes.

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Conflict of interest statement

Acknowledgements: The authors thank the participants and staff of the NHS, NHSII and HPFS for their valuable contributions. Some of the data were presented as an abstract at the American Heart Association's Epidemiology and Prevention/Lifestyle and Cardiometabolic Health 2023 Scientific Sessions. Data availability: The datasets analysed during the current study are available from the corresponding author on request. Funding: The research reported in this manuscript was supported by National Institutes of Health grants UM1 CA186107, U01 CA167552 and U01 CA176726. Additionally, this work was supported by grant T32 DK007703-26 (LSP), K01HL169414 (LSP) from the National Heart, Lung, and Blood Institute and K01 DK136968 (DEH) from the National Institute of Diabetes and Digestive and Kidney Diseases. Other funding sources include R01DK125803 (DKT), R01DK131753 (SNB), R01DK120560 (SNB) and R01DK125273 (CBE) from the National Institutes of Health, the Thrasher Research Fund (CBE), the New Balance Foundation (CBE), the Arnold Ventures (CBE) and Dairy Farmers of Canada (J-PD-C), and the Novo Nordisk Foundation grant NNF18CC0034900 (MG-F). Authors’ relationships and activities: LSP has been supported by grants T32 DK007703-26 from the NIH; DKT has been supported by grant R01DK125803 from the NIH and is currently a member of the 2025 US Dietary Guidelines Scientific Advisory Committee, reviewing beverages and cardiovascular disease; SNB has been supported by grants R01DK131753 and R01DK120560 from the NIH and discloses a pending patent entitled ‘system and methods for conducting nutritional health risk assessments and adapting risk analyses based on actual health outcomes’ (provisional application filed on 20 May 2022; US Application No. 63/344,293); WCW is part of the EAT Foundation Advisory Board (unpaid position) and receives royalties for the textbook Nutritional Epidemiology, Oxford University Press; DSL discloses royalties for a book that recommends a carbohydrate-modified diet; CBE has been supported by grant R01DK125273 from the NIH, as well as grants from the Thrasher Research Fund, New Balance Foundation, and Arnold Ventures, and honoraria from the Columbia Cornell Obesity course and the University of Arkansas for Medical Sciences (speaker); J-PD-C has been supported by grants and received payments (research grant review committee) from the Dairy Farmers of Canada. MG-F is supported by a Novo Nordisk Foundation grant NNF18CC0034900. MG-F is the PI of a grant from the International Nut Council (INC). All other authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work. Contribution statement: LSP formulated the study question and design, performed the statistical analyses, interpreted the results and wrote the complete first draft of the manuscript. DKT, YL, SNB, DEH, J-PD-C, DSL, CBE and WCW revised and edited the manuscript and made substantial contributions to the interpretation of data. FBH and MG-F formulated the study question and design, interpreted the results and edited the manuscript. FBH and WCW obtained funding. YL assisted in statistical analyses and interpretation of data. All authors participated in critical revision of the manuscript and approved the final version of the manuscript. The corresponding author (LSP) and senior author (MG-F) take full responsibility for the work and/or the conduct of the study, had access to the data and controlled the decision to publish.

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