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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Program codes used for statistical analyses are available from the authors upon reasonable request.
International Diabetes Federation. IDF Diabetes Atlas, 9th ed. Brussels, Belgium: International Diabetes Federation (IDF); 2019.
Janket SJ, Manson JE, Sesso H, Buring JE, Liu S. A prospective study of sugar intake and risk of type 2 diabetes in women. Diabetes Care. 2003;26:1008–15.
Barclay AW, Flood VM, Rochtchina E, Mitchell P, Brand-Miller JC. Glycemic index, dietary fiber, and risk of type 2 diabetes in a cohort of older Australians. Diabetes Care. 2007;30:2811–3.
Montonen J, Jarvinen R, Knekt P, Heliovaara M, Reunanen A. Consumption of sweetened beverages and intakes of fructose and glucose predict type 2 diabetes occurrence. J Nutr. 2007;137:1447–54.
Sluijs I, Beulens JW, van der Schouw YT, van der AD, Buckland G, Kuijsten A, et al. Dietary glycemic index, glycemic load, and digestible carbohydrate intake are not associated with risk of type 2 diabetes in eight European countries. J Nutr. 2013;143:93–9.
Ahmadi-Abhari S, Luben RN, Powell N, Bhaniani A, Chowdhury R, Wareham NJ, et al. Dietary intake of carbohydrates and risk of type 2 diabetes: the European Prospective Investigation into Cancer-Norfolk study. Br J Nutr. 2014;111:342–52.
Schulze MB, Schulz M, Heidemann C, Schienkiewitz A, Hoffmann K, Boeing H. Carbohydrate intake and incidence of type 2 diabetes in the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Br J Nutr. 2008;99:1107–16.
Colditz GA, Manson JE, Stampfer MJ, Rosner B, Willett WC, Speizer FE. Diet and risk of clinical diabetes in women. Am J Clin Nutr. 1992;55:1018–23.
Hodge AM, English DR, O’Dea K, Giles GG. Glycemic index and dietary fiber and the risk of type 2 diabetes. Diabetes Care. 2004;27:2701–6.
Meyer KA, Kushi LH, Jacobs DR Jr., Slavin J, Sellers TA, Folsom AR. Carbohydrates, dietary fiber, and incident type 2 diabetes in older women. Am J Clin Nutr. 2000;71:921–30.
Sonestedt E, Overby NC, Laaksonen DE, Birgisdottir BE. Does high sugar consumption exacerbate cardiometabolic risk factors and increase the risk of type 2 diabetes and cardiovascular disease? Food Nutr Res. 2012;56. https://doi.org/10.3402/fnr.v56i0.19104. e-pub 2012/7/30
Imamura F, O’Connor L, Ye Z, Mursu J, Hayashino Y, Bhupathiraju SN, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. 2015;351:h3576.
Lean ME, Te Morenga L. Sugar and Type 2 diabetes. Br Med Bull. 2016;120:43–53.
Neuenschwander M, Ballon A, Weber KS, Norat T, Aune D, Schwingshackl L, et al. Role of diet in type 2 diabetes incidence: umbrella review of meta-analyses of prospective observational studies. BMJ. 2019;366:l2368.
Stanhope KL, Schwarz JM, Keim NL, Griffen SC, Bremer AA, Graham JL, et al. Consuming fructose-sweetened, not glucose-sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in overweight/obese humans. J Clin Investig. 2009;119:1322–34.
Schwarz JM, Noworolski SM, Wen MJ, Dyachenko A, Prior JL, Weinberg ME, et al. Effect of a High-Fructose Weight-Maintaining Diet on Lipogenesis and Liver Fat. J Clin Endocrinol Metab. 2015;100:2434–42.
Johnson RJ, Perez-Pozo SE, Sautin YY, Manitius J, Sanchez-Lozada LG, Feig DI, et al. Hypothesis: could excessive fructose intake and uric acid cause type 2 diabetes? Endocr Rev. 2009;30:96–116.
Villegas R, Liu S, Gao YT, Yang G, Li H, Zheng W, et al. Prospective study of dietary carbohydrates, glycemic index, glycemic load, and incidence of type 2 diabetes mellitus in middle-aged Chinese women. Arch Intern Med. 2007;167:2310–6.
Nanri A, Mizoue T, Noda M, Takahashi Y, Kato M, Inoue M, et al. Rice intake and type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Am J Clin Nutr. 2010;92:1468–77.
Watanabe S, Tsugane S, Sobue T, Konishi M, Baba S. Study design and organization of the JPHC study. Japan Public Health Center-based Prospective Study on Cancer and Cardiovascular Diseases. J Epidemiol. 2001;11:S3–7.
Tsugane S, Sawada N. The JPHC study: design and some findings on the typical Japanese diet. Jpn J Clin Oncol. 2014;44:777–82.
Sasaki S, Kobayashi M, Ishihara J, Tsugane S. Self-administered food frequency questionnaire used in the 5-year follow-up survey of the JPHC Study: questionnaire structure, computation algorithms, and area-based mean intake. J Epidemiol 2003 Jan;13:S13–22.
Ministry of Education Culture, Sports, Science and Technology, Japan. Standard Tables of Food Composition in Japan (7th Revised Ed). Tokyo, Japan: Official Gazette Cooperation of Japan; 2015.
Ministry of Education Culture, Sports, Science and Technology, Japan. Standard Tables of Food Composition in Japan (7th Revised Ed), Available Carbohydrates, Polyols, and Organic Acids. Tokyo, Japan: Official Gazette Cooperation of Japan; 2015.
Pollock NK, Bundy V, Kanto W, Davis CL, Bernard PJ, Zhu H, et al. Greater fructose consumption is associated with cardiometabolic risk markers and visceral adiposity in adolescents. J Nutr. 2012;142:251–7.
Kanehara R, Goto A, Kotemori A, Mori N, Nakamura A, Sawada N, et al. Validity and Reproducibility of a Self-Administered Food Frequency Questionnaire for the Assessment of Sugar Intake in Middle-Aged Japanese Adults. Nutrients. 2019;11:554.
Waki K, Noda M, Sasaki S, Matsumura Y, Takahashi Y, Isogawa A, et al. Alcohol consumption and other risk factors for self-reported diabetes among middle-aged Japanese: a population-based prospective study in the JPHC study cohort I. Diabet Med. 2005;22:323–31.
Harrell F. Regression Modeling Strategies with Applications to Linear Models, Logistic and Ordinal Regression, and Survival Analysis (2nd Ed). Heidelberg, Germany: Springer International Publishing; 2015.
Liu Y, De A. Multiple Imputation by Fully Conditional Specification for Dealing with Missing Data in a Large Epidemiologic Study. Int J Stat Med Res. 2015;4:287–95.
World Health Organization. Guideline: Sugars Intake for Adults and Children. Geneva, Switzerland: WHO Document Production Services; 2015.
Liu S, Choi HK, Ford E, Song Y, Klevak A, Buring JE, et al. A prospective study of dairy intake and the risk of type 2 diabetes in women. Diabetes Care. 2006;29:1579–84.
Sluijs I, Forouhi NG, Beulens JW, van der Schouw YT, Agnoli C, Arriola L, et al. The amount and type of dairy product intake and incident type 2 diabetes: results from the EPIC-InterAct Study. Am J Clin Nutr. 2012;96:382–90.
Sluijs I, van der Schouw YT, van der AD, Spijkerman AM, Hu FB, Grobbee DE, et al. Carbohydrate quantity and quality and risk of type 2 diabetes in the European Prospective Investigation into Cancer and Nutrition-Netherlands (EPIC-NL) study. Am J Clin Nutr. 2010;92:905–11.
Nanri A, Mizoue T, Kurotani K, Goto A, Oba S, Noda M, et al. Low-carbohydrate diet and type 2 diabetes risk in Japanese men and women: the Japan Public Health Center-Based Prospective Study. PLoS ONE. 2015;10:e0118377 https://doi.org/10.1371/journal.pone.0118377. e-pub ahead of print 2015/02/20
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 https://epi.ncc.go.jp/en/jphc/781/index.html. 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).
The authors declare no competing interests.
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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). https://doi.org/10.1038/s41430-021-01005-1