Associations of diet soda and non-caloric artificial sweetener use with markers of glucose and insulin homeostasis and incident diabetes: the Strong Heart Family Study

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Non-caloric artificial sweeteners (NAS) are marketed as healthier alternatives to sugar, but the relationship between consumption of NAS and development of diabetes is unclear. This study assessed the associations of diet soda and NAS consumption with (1) early markers of insulin and glucose homeostasis (cross-sectionally) and (2) incident diabetes (over an average of 8 years of follow-up) among American Indians, a population with high rates of obesity.


The study population included Strong Heart Family Study participants without cardiovascular disease or diabetes who participated in the 2007–2009 study exam (n = 1359). Diet soda and NAS consumption were assessed using a Block food frequency questionnaire and supplemental NAS questionnaire at the study exam. Fasting plasma glucose and insulin were measured during the study exam after a 12-h overnight fast. Participants were followed for incident diabetes through December 2017 using a single phone interview and medical record review; diabetes was identified by self-report and confirmed by documentation in medical records. Associations of diet soda and NAS consumption with fasting insulin, glucose, and incident diabetes were assessed using generalized estimating equations (fasting insulin and glucose analyses) and parametric survival models with Weibull distributions (incident diabetes analyses).


Just under half of participants reported regularly consuming diet soda (40%) or using NAS to sweeten their beverages (41%). During an average 8 years of follow-up, we identified 98 cases of incident diabetes. After correction for multiple comparisons, there were no statistically significant associations of reported diet soda and NAS consumption with fasting insulin, fasting glucose, or incident diabetes.


Although reported consumption of diet soda and NAS were high, neither were associated with diabetes risk.

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Data availability

Due to privacy agreements with the tribal communities involved in this study, access to study data are restricted. Further information can be found at https://strongheartstudy.org/.


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We thank the study participants and the Strong Heart Study staff.


The Strong Heart Family Study is supported by the National Institutes of Health cooperative agreement grants U01-HL41642, U01-HL41652, U01-HL41654, U01-HL65520, and U01-HL65521 and research grants R01-HL109315, R01-HL109301, R01-HL109284, R01-HL109282, and R01-HL109319. AMF is also supported by 5KL2TR000421.

Author information

PNJ drafted the manuscript, analyzed the data, had full access to the data in the study, and had final responsibility for the decision to submit for publication. LB, MO, RBD, SAC, JWM, TA, ETL, FLY, and JY contributed to the interpretation of results and critically reviewed the manuscript. JGU and BVH contributed to the conception and design of the study, the acquisition of data, and critically reviewed the manuscript. AMF contributed to the conception and design of the study, the data analysis, and critically reviewed the manuscript. All authors approved the final version and agreed to be accountable for all aspects of the work.

Correspondence to Paul N. Jensen.

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