Calibrated Total Sugars Intake and Risk of Type 2 Diabetes in the Women's Health Initiative Observational Study
Authors: Tasevska Natasha , Pettinger Mary , Kipnis Victor , Midthune Douglas , Tinker Lesley , Potischman Nancy , Neuhouser Marian , Beasley Jeannette , Van Horn Linda , Howard Barbara , Liu Simin , Manson JoAnn , Shikany James , Thomson Cynthia , Prentice Ross 
Published: November 2023

BackgroundThe prospective evidence on the association between total sugars and risk of type 2 diabetes (T2D) has been inconclusive, which may be due to measurement error (ME) in self‐reported diet.ObjectiveTo prospectively investigate the association between total sugars intake and T2D risk in a cohort of postmenopausal women after ME correction of self‐reported intake.MethodsWe used data from 80,654 postmenopausal women aged 50–79, from the Women's Health Initiative (WHI) Observational Study. Total sugars (sum of individual monosaccharides ‐ glucose, fructose, galactose, and disaccharides ‐ sucrose, lactose and maltose; not discriminating added from naturally‐occurring sugars) and energy intake assessed by the WHI Food frequency questionnaire, and self‐reported physical activity (PA) were calibrated using biomarker‐based calibration equations developed from a WHI biomarker sub‐study. We report multivariable hazard ratios (HRs) and 95% Confidence Intervals (CI) of self‐reported T2D for the 5th vs. 1st quintile of calibrated total sugars, from an energy‐substitution (ES) and energy‐partition (EP) Cox proportional hazards models adjusted for age, calibrated total energy (ES) or calibrated non‐sugars energy intake (EP), body mass index (BMI), waist circumference (WC), race, marital status, education, smoking, hormone replacement therapy use, history of hypertension, alcohol intake, history of cardiovascular disease, hypercholesterolemia, family history of T2D, and calibrated PA.ResultsAfter up to 16 years of follow‐up, we identified 7,128 incident cases of T2D. We found inverse association between calibrated total sugars intake and T2D risk (HR Q5 vs. Q1: 0.64; 95% CI: 0.53, 0.76; Ptrend<0.0001), in ES multivariable model adjusted for calibrated total energy intake. In EP model while controlling for calibrated non‐sugars energy intake, we found a non‐significant increase in T2D risk in participants in the 5th vs. 1st quintile of calibrated sugars intake (HR Q5 vs. Q1: 1.22; 95% CI: 0.92, 1.62; Ptrend=0.35). The HRs estimates were somewhat altered when BMI and WC were removed from the models (ES model: HR Q5 vs. Q1: 0.56; 95% CI: 0.44, 0.72; Ptrend<0.0001 in ES; EP model: HRQ5 vs. Q1: 1.42; 95% CI: 0.87, 2.31; Ptrend=0.22). Calibrated protein had no effect on the observed associations.ConclusionWe observed contrasting results for the association between calibrated total sugars and T2D risk in an ES vs. EP model. In the EP model, there is a suggestion for an increase in T2D risk with high total sugars intake. The inverse association observed in the ES model may be due to substituting sugars for energy‐contributing nutrients not in the model, such as fat, for which no calibrated estimates were available.Support or Funding InformationThe Women's Health Initiative program is funded by the National Heart, Lung, and Blood Institute, the NIH, and the US Department of Health and Human Services (contracts N01WH22110, 24152, 32100‐2, 32105‐6, 32108‐ 9, 32111‐13, 32115, 32118‐32119, 32122, 42107‐26, 42129‐32, and 44221).