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Nutrition and Health (including climate and ecological aspects)

Association between sugar and starch intakes and type 2 diabetes risk in middle-aged adults in a prospective cohort study



We aimed to investigate the association between sugar or starch intake and the risk of type 2 diabetes (T2D) in middle-aged Japanese adults.


Participants comprised 27,797 men and 36,880 women aged 45–75 years with no history of diabetes and critical illness before the second survey in the Japan Public Health Center-based Prospective Study. We calculated sugar (total sugar, total fructose, and sugar subtypes) and starch intakes (% energy/d) using a validated 147-item food frequency questionnaire, to estimate the average dietary intake over the previous year. T2D onset was defined by validated self-reports. ORs adjusted for potential confounders were estimated using multiple logistic regression with categorical and cubic spline models.


During the 5-year follow-up, 690 men and 500 women were identified with T2D. In women, the quartiles of total sugar or total fructose intakes were not significantly associated with T2D risk; however, the spline curves showed an increased risk at extremely high intake levels (ORs [95% CI]: 1.88 [1.07–3.31] at 30% energy/d for total sugar and 1.87 [1.10–3.16] at 14% energy/d for total fructose). Starch intake was positively associated with T2D risk among women in the categorical and spline models (ORs [95% CI]: 1.55 [1.13–2.12] at 50% energy/d). In men, sugar and starch intakes were not associated with T2D risk.


In this large-scale population-based cohort study, starch intake was associated with an increased T2D risk in Japanese women. An increased risk with extremely high intake of total sugar or total fructose among women cannot be disregarded.

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Fig. 1: Restricted cubic spline for the association between total sugar, total fructose, and starch intake and risk of type 2 diabetes.

Code availability

Program codes used for statistical analyses are available from the authors upon reasonable request.


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We thank all members in each study area and at the central office for their efforts in the survey. The members of the JPHC Study Group are listed at In addition, we are grateful to Professor Yukari Kawano, Department of Nutritional Science, Faculty of Applied Bioscience, Tokyo University of Agriculture, Drs Sarah K. Abe, Nagisa Mori, and Mayo Hirabayashi of the National Cancer Center Japan, and Dr Ayaka Kotemori, Department of Food and Life Science, School of Life and Environmental Science, Azabu University, for their helpful comments on the analyses and discussion in this study.


The present study was supported by the JSPS KAKENHI (grant number 15K21389, 18K10095) from the Japan Society for the Promotion of Science (JSPS); the National Cancer Center Research and Development Fund (since 2011); and a Grant-in-Aid for Cancer Research from the Ministry of Health, Labor and Welfare of Japan (from 1989 to 2010).

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The authors responsibilities were as follows—ST designed the research; ST, NS, MI, and MN conducted the research; RK analyzed the data; RK and AG wrote the paper; AG had primary responsibility for final content; RK, AG, NS, TM, MN, AH, MI, and ST were involved in interpretation of the results and revision of the paper; All authors read and approved the final paper.

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Correspondence to Atsushi Goto.

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Kanehara, R., Goto, A., Sawada, N. et al. Association between sugar and starch intakes and type 2 diabetes risk in middle-aged adults in a prospective cohort study. Eur J Clin Nutr (2021).

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