British Journal of Nutrition

Full Papers

Human and Clinical Nutrition

Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose–response meta-analysis of prospective studies

D. C. Greenwooda1 c1, D. E. Threapletona2, C. E. L. Evansa2, C. L. Cleghorna2, C. Nykjaera2, C. Woodheada2 and V. J. Burleya2

a1 Division of Epidemiology and Biostatistics, Level 8, Worsley Building, University of Leeds, Leeds LS2 9JT, UK

a2 Nutritional Epidemiology Group, School of Food Science and Nutrition, University of Leeds, Leeds LS2 9JT, UK


The intake of sugar-sweetened soft drinks has been reported to be associated with an increased risk of type 2 diabetes, but it is unclear whether this is because of the sugar content or related lifestyle factors, whether similar associations hold for artificially sweetened soft drinks, and how these associations are related to BMI. We aimed to conduct a systematic literature review and dose–response meta-analysis of evidence from prospective cohorts to explore these issues. We searched multiple sources for prospective studies on sugar-sweetened and artificially sweetened soft drinks in relation to the risk of type 2 diabetes. Data were extracted from eleven publications on nine cohorts. Consumption values were converted to ml/d, permitting the exploration of linear and non-linear dose–response trends. Summary relative risks (RR) were estimated using a random-effects meta-analysis. The summary RR for sugar-sweetened and artificially sweetened soft drinks were 1·20/330 ml per d (95 % CI 1·12, 1·29, P< 0·001) and 1·13/330 ml per d (95 % CI 1·02, 1·25, P= 0·02), respectively. The association with sugar-sweetened soft drinks was slightly lower in studies adjusting for BMI, consistent with BMI being involved in the causal pathway. There was no evidence of effect modification, though both these comparisons lacked power. Overall between-study heterogeneity was high. The included studies were observational, so their results should be interpreted cautiously, but findings indicate a positive association between sugar-sweetened soft drink intake and type 2 diabetes risk, attenuated by adjustment for BMI. The trend was less consistent for artificially sweetened soft drinks. This may indicate an alternative explanation, such as lifestyle factors or reverse causality. Future research should focus on the temporal nature of the association and whether BMI modifies or mediates the association.

(Received November 18 2013)

(Revised April 23 2014)

(Accepted May 08 2014)

(Online publication June 16 2014)

Key Words:

  • Sugar;
  • Soft drinks;
  • Meta-analyses;
  • Type 2 diabetes


c1 Corresponding author: D. C. Greenwood, fax +44 113 343 4877, email


  Abbreviations: EPIC, European Prospective Investigation into Cancer and Nutrition; RR, relative risk