Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S675–S678

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Diabetes & Metabolic Syndrome: Clinical Research &

Reviews
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Original Article

Sugar-sweetened beverages consumption is associated with abdominal

obesity risk in diabetic patients
Razieh Anaria , Reza Amanib,c,* , Masoud Veissic
a
Department of Nutrition, Faculty of Autonomous Campus (Arvand International Unit), Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
b
Food Security Research Center, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran
c
Department of Nutrition, Faculty of Paramedicine, Health Research Institute, Nutrition and Metabolic Disease Research Center, Ahvaz Jundishapur University
of Medical Sciences, Ahvaz, Iran

A R T I C L E I N F O A B S T R A C T

Aim: Sugar sweetened beverages (SSBs) are any beverages containing added-sugar and supposed to
Keywords: increase body lipogenesis and fat accumulation in healthy subjects. This study was performed to assess
Sugar-sweetened beverages
the possible association between SSBs consumption and obesity in type 2 diabetes (T2DM) patients.
Diabetes
Abdominal obesity
Methods: T2DM adults with no insulin treatment entered the study. Abdominal obesity and general
General obesity adiposity were determined using waist circumference (WC) and body mass index (BMI), respectively.
Smoking SSBs intake was extracted from a validated food frequency questionnaire.
Results: Mean SSBs intake was 0.6 serving/d (145.6 mL/d). There was no considerable association between
SSBs intake and gender. About 46% of patients consumed at least one serving of SSBs per week. SSBs
consumption was correlated neither to WC nor to BMI. After adjustment for confounding factors,
abdominal obesity was associated with drinking SSBs 1 serving/week (OR = 4.93, 95% CI: 1.35–18.03),
and SSB 3 serving/week (OR = 5.07, 95% CI: 1.22–21.15) compared to those consumed <1 serving/week.
This association was not found for general obesity (OR = 0.88, 95% CI: 0.60–1.23). Ex-smokers had higher
SSBs intake compared to those never smoked (OR = 3.94, 95% CI = 1.06–14.71). Energy intake and
macronutrients were similar in both SSBs sub-groups. Mean daily energy supplied by SSBs was 120 kcal in
participants having 1 serving of SSBs/week and 2.7 kcal in <1 serving SSBs/week (OR = 1.14, 95% CI:
1.09–1.20). Lower SSBs drinkers had 17% higher fiber intake (OR = 0.83, 95% CI = 0.73–0.96).
Conclusion: SSBs intake might increase abdominal obesity in diabetic population and therefore should be
considered in diabetes control procedure.
© 2017 Published by Elsevier Ltd on behalf of Diabetes India.

1. Introduction Beverages are important dietary components affecting our health

There has been an elevation in the burden of obesity and diet-
related chronic diseases in last decades. Overweight and obesity
are major risk factors for non-communicable diseases such as
cardiovascular diseases (mainly heart disease and stroke), diabe-
tes, and some types of cancer [1]. There has also been an increasing
trend in the prevalence of obesity in Iran by 21.7% of adults [2].
Nutritional transition to calorie dense foods like sugar added
foods and beverages and physical inactivity are two major
contributors in obesity increment in most countries [3–5].
* Corresponding author at: Food Security Research Center, School of Nutrition
and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran.
E-mail addresses: Raziehanari85@yahoo.com (R. Anari), r_amani@mail.mui.ac.ir
, Rezaamani@hotmail.com (R. Amani), m_veissi@yahoo.com (M. Veissi).
through various mechanisms [6].
SSBs are any type of beverages containing added caloric
sweeteners including soft drinks, fruit juices and other sugar-
added drinks [7]. There is growing evidence that SSBs intake is
associated with an elevated risk of obesity and weight gain [8,9],
and CVD [10].
The American Heart Association recommends that women
consume no more than 25 g (100 kcal) and men no more than
37.5 g (150 kcal) of added sugars per day [11].
Confining the beverages with added sugars in diabetes mellitus
afflicts is also frequently advised by national organizations like the
American Cancer Society, the American Diabetes Association, and
the American Heart Association [12]. Findings from well-designed
prospective epidemiological studies have shown consistent posi-
tive associations between SSB intake and weight gain and obesity
in both children and adults [8]. SSBs lead to weight gain by their

http://dx.doi.org/10.1016/j.dsx.2017.04.024
1871-4021/© 2017 Published by Elsevier Ltd on behalf of Diabetes India.
S676 R. Anari et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S675–S678
high sugar content and incomplete compensation for total energy
at subsequent meals after intake of liquid calories [8].
Up to now, global evidence [13] and national data from Tehran
Lipid and Glucose Study (TLGS) [14] have reported SSBs
consumption in healthy adults, however, there is no sufficient
data on SSBs intake in diabetic patients [15,16]. Also, no data is
currently available from Iranian T2DM patients. We aimed to
determine SSBs intake in adults with type 2 diabetes and to
evaluate its association with obesity.
2. Materials & methods
2.1. Subjects
This study was a cross-sectional research performed on 222
T2DM outpatient adults (mean age: 54.5  9.4 years old) attending
to Diabetes Clinic of Golestan Hospital, Ahvaz. Diabetes had
previously been diagnosed by a general practitioner according to
American Diabetes Association (ADA) criteria [17]. T2DM subjects
under insulin therapy or having a serious disease, such as cancer or
severe kidney disease, were excluded from the primary sample.
The final sample included 157 subjects. All patients declare their
consent through a written form. Study protocol was approved by
Ahvaz Jundishapur University of Medical Sciences (AJUMS) Ethics
Committee.
2.2. Variables measurement
Demographic data including participants' age, gender, smoking
status and physical activity and anthropometric measures,
including weight, height, body fat percentage, body mass index
(BMI), and waist circumference (WC) were recorded. Abdominal
obesity was determined using International Diabetes Federation
definition that considers WC 94 cm for men and WC 80 cm for
women as abdominal obesity [17] and BMI  30 kg/m2 was used to
distinguish general obesity. SSBs consumption pattern was
extracted from a semi-quantitative validated food frequency
questionnaire [18]. Questions on frequency and amount of SSBs
consumption including any sweetened beverage like syrup,
cordials, sugary milk or sweetened tea/coffee were recorded
through face-to-face interview.
2.3. Statistical analyses
Patients were categorized into two equal groups according to
their usual SSBs intake: less than 1 serving/week and equal or more
than 1 serving/week. Data were entered to nutritional software
NUTRITIONIST-4 modified for Iranian population. SPSS software
version 21 was utilized to analyze the data. Significant values were
identified via two-tailed p-values less than 0.05. Chi squared and t-
tests were used to analyze qualitative and quantitative data.
Pearson's correlation (2-tailed) was applied to find any correlations
between two quantitative variables.
3. Results
Mean SSBs intake in diabetic patients was 145.60 mL equaled to
0.61 serving per day (1 serving = 8 Ounce). About half of
participants (46%) consumed at least one serving of SSBs in a
week. On average, SSBs supplied 56.21 7.68 kcal in a given day
(Table 1).
There was no difference between men and women for SSBs
intake after adjustment for age and diabetes duration (OR = 0.97,
95% CI: 0.49–1.91).
SSBs provided about 3% of daily energy intake which allocated
one-fourth of calorie intake from all consumed beverages (Table 1).
Table 1
Basic characteristics of participants.
Basic characteristics Mean SE
Age (year) 54.47  0.75
Diabetes duration (year) 6.36  0.52
Sugar-sweetened beverages (serving/d) 0.61  0.08
Sugar-sweetened beverages (mL/d) 145.60  19.68
Sugar-sweetened beverages (kcal/d) 56.21  7.68
Daily energy intake from SSBs (%) 2.28  0.30
Energy intake (kcal/d) 2590.94  70.11
Dietary Carbohydrate (%) 58.01  0.71
Dietary Protein (%) 13.33  0.18
Dietary Fat (%) 28.50  0.71
Dietary Fiber (gr/d) 21.28  0.71
Men consuming SSBs 1 serving/week had higher prevalence of
abdominal obesity than those had SSBs less than once a week
(87.5% vs. 55.2%, p = 0.016; Fig. 1). However, this association was not
observed for general adiposity in both genders (p > 0.05).
SSBs consumption was correlated neither to WC nor to BMI. On
the other hand, abdominal obesity was increased in patients
drinking SSBs 1 serving/week (OR = 4.93, 95% CI: 1.35–18.03), and
SSB 3 serving/week (OR = 5.07, 95% CI: 1.22–21.15) compared to
those consumed <1 serving/week, after adjustment for energy
intake, age and sex. However, no association was found regarding
the general obesity and SSBs intake between these sub-groups
(OR = 1.05, 95% CI: 0.55–2.00; Table 2) or within both genders
(Fig. 1).
Age, gender, BMI, WC, and body fat percent did not show any
different values in two SSBs consumption groups (<1 vs. 1
serving/wk, Table 2). After adjusting the confounding factors,
diabetics who were ex-smokers had about 4 times higher
consumption of SSBs (1 serving/wk.) in comparison to those
never smoked (OR = 3.94, 95% CI: 1.06–14.71; Table 2). Current
smokers had also increased SSBs consumption at least once a week,
however it was not significant (OR = 4.79, 95% CI: 0.79–29.12;
Table 2).
Participants having at least 1 serving of SSBs a week gained on
average 120 kcal/day from SSBs, however, it was 2.7 kcal/day in
subjects who consumed less than 1 serving SSBs/week (OR = 1.14,
95% CI: 1.09–1.20; Table 2). Energy intake and macronutrients were
similar in both SSB sub-groups (p > 0.05, Table 2). Although protein
intake was higher in the lower SSBs group (i.e. <1 serving/week), it
was near significant after adjustment for confounding factors
(13.7% vs. 12.9%, OR = 0.86, 95% CI = 0.73–1.01, p = 0.062; Table 2).
Dietary fiber consumed in lower SSBs drinkers was 17% higher than
the higher SSBs group (OR = 0.83, 95% CI = 0.73–0.96 after adjust-
ment; Table 2).
4. Discussion
High prevalence of central obesity has been recently reported in
Iranian diabetic patients (68.8%) [19]. This was higher than other
Asian countries, such as India (67%), Pakistan (61.5%), China
(54.8%), and Korea (37.2%) [20].
SSBs containing high amount of added sugars and energy have
been considered as a cause for weight gain and obesity [8]. Global
consumption of SSBs has been reported 0.58 serving/day [15].
Recently, Tehran Lipid and Glucose Study (TLGS) reported the daily
intake of SSBs was 0.25 serving in Iranian adults [14]. The results of
our study demonstrated that diabetic participants consumed on
average 0.6 serving/d of SSBs which was equal to global [15] but
higher than regional estimations [14]. Although, the amount did
not exceed the recommendations defined by international
federations [11,12].
 R. Anari et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S675–S678 S677

120 Male central obesity

Male general obesity

96.4 97.9
100
87.5 Female central obesity

Percentage (%)
80 Female general obesity

60 55.2
50
46.4
40

17.2
20 12.5

0
<1 serving/week ≥1 serving/week

Figure. 1. Prevalence of central an general obesity between two genders.

In our study, diabetic patients demonstrated considerable
amounts of SSBs consumption rather than previous studies in
general [14] and also diabetic population [15,16]. It is suggested
that replacement of sugar-sweetened beverages with milk,
particularly low-fat milk, might have favorable effects on
metabolic outcomes and obesity [8,21].
The mean calorie intake from SSBs in our sample was 56.2 kcal/
d or 3% of energy intake which was lower than Latinos with T2DM
with 163 kcal/day (9.6% of total calorie intake) [16]. Our findings
demonstrated that 46% of subjects consumed SSBs regularly which
was in line with another study indicated that 45% of adults with
T2DM consumed SSBs on a given day (average 202 kcal/day) [15],
however mean calorie from SSBs in our subjects was lower. The
American Heart Association recommends that women consume no
more than 25 g (100 kcal) and men no more than 37.5 g (150 kcal) of
added sugar per day [11].
Current study revealed that abdominal obesity was associated
with higher SSBs intake. Central obesity contributes to increased
risk of cardiovascular disease [19,22].
Also, SSBs may increase the risk of metabolic syndrome and
type 2 diabetes not only through obesity but also by increasing
dietary glycemic load, leading to insulin resistance, b-cell
dysfunction, and inflammation [23].
In this study, SSBs consumption limited to less than one serving
per week was associated with about 5 times lower rate of
abdominal obesity compared to SSBs 1 serving/week. However,
in both SSBs categories only one-third of participants suffered from
general obesity (Table 2).

Table 2
Demographic and dietary difference between the two sugar sweetened beverages consumption sub-groups.

Variable SSBs intake OR 95% CI p-value

<1 serving/wk 1 serving/wk

(N = 85) (N = 72)
Age (year) 55.62 (9.20) 53.10 (9.49) 0.97 0.94–1.01 0.145
Female (%) 65.9 66.7 1.03 0.50–2.11 0.948
Body fat%)) 35.66 (10.50) 37.19 (9.83) 1.04 0.98–1.09 0.195
BMI (Kg/m2) 28.88 (5.40) 29.70 (4.57) 1.028 0.96–1.10 0.425
WC (cm) 97.81 (10.59) 99.28 (9.73) 1.02 0.99–1.05 0.370
Smoking status (%)
Never 57.4 42.6 Reference Reference –
Current 2.4 6.9 4.79 0.79–29.12 0.089
Former 5.9 12.5 3.94 1.06–14.71 0.041*
SSB (Kcal/day) 2.65 (7.86) 119.46 (113.0) 1.14 1.09–1.20 <0.001*
Energy (kcal/d) 2537.94 (852.56) 2653.51 (910.11) 1.00 0.98–1.00 0.719
Dietary Carbohydrate (%) 56.89 (10.20) 59.32 (6.88) 1.03 1.00–1.08 0.091
Dietary Protein (%) 13.66 (2.34) 12.94 (1.98) 0.86 0.73–1.01 0.062
Dietary Fat (%) 29.29 (10.14) 27.57 (7.13) 0.98 0.94–1.02 0.225
General obesity (%) 36.5 37.5 1.05 0.55–2.00 0.894
Abdominal obesity (%) 82.4 94.4 4.93 1.35–18.03 0.016*
Fiber (gr/1000 kcal) 8.84 (2.70) 7.71 (2.17) 0.83 0.73–0.96 0.009*

Values are mean (SD) except stated. P-values are reported after adjustment for energy intake, age and sex.
BMI Body mass index; SSB Sugar sweetened beverage; WC Waist circumference; wk week.
*
p < 0.05 is significant.
S678 R. Anari et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews 11S (2017) S675–S678
Results also indicated that BMI had no considerable link to SSBs
consumption that was in agreement with Sun and Empie's finding
from a meta-analysis [24].
Our diabetics who were ex-smoker had 4 times higher SSBs
intake (p < 0.05), but no association was found in current smokers.
This was in contrast with previous study by Ejtahed et al. that
showed higher SSBs consumption in current smokers [25].
This study demonstrated SSBs consumption was associated
with about 5 times greater risk of abdominal obesity. Due to the
higher risk of cardiovascular events in obese diabetic persons [8]
and also triggering effect of obesity on insulin resistance [24],
limiting such beverages is extremely advisable to these people.
Reducing or eliminating SSB intake might be a robust strategy
for adults with diabetes to decrease consumption of added sugars
for better glycemic control [23] as well as for better weight
management [26].
Vartanian et al. found associations between SSB consumption
and increased energy intake and body weight, lower intake of
calcium and other nutrients, and increased risk of medical
problems such as type 2 diabetes, hypocalcemia, dental caries,
and elevated blood pressure [27].
In March 2014, the World Health Organization (WHO) released
draft guidelines with recommendations on limiting sugar con-
sumption (through food and beverage) to reduce public health
problems like obesity and recommended decreasing the total
energy intake of sugar from 10% (since 2002) to 5% in a day [28].
Although our results showed that the diabetic patients consumed
higher SSBs than that of healthy population [14], the amount is still
lower than limits.
There were also some limitations for this study. As this was a
cross-sectional examination, no causal relationship can be drawn
between SSBs intake and obesity status in diabetic patients. Using
FFQ and underreporting dietary intake are other possible
limitations, which might affect our results. Therefore, long-term
interventions towards SSBs role in obesity and possible mecha-
nisms are highly recommended.
To sum up, our findings support a strong association between
SSBs and elevated risk of abdominal obesity. Thus, decreasing SSBs
intake is a simple dietary strategy that would help T2DM patients
to decline their waist circumference and visceral adiposity and
hence, to diminish diabetes-related negative health outcomes.
Conflicts of interest
None.
Acknowledgements
This work was a part of Razieh Anari’s Master thesis. R. Anari
collected data and interviews and wrote the first draft of
manuscript. R. Amani and M. Veissi supervised the research. H.
B. Shahbazian did the clinical assistance. R. Anari and S.M. Latifi
performed statistical analyses. R. Amani did the final revision. The
authors would like to thank the personnel of Golestan Diabetes
Clinic, Ahvaz and all participants.
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