Abstract
Purpose:
This study assessed the associations between sociodemographic and behavioral characteristics and sugar-sweetened beverage (SSB) intake among US adults with diabetes or prediabetes.
Design:
Quantitative, cross-sectional study.
Setting:
The 2013 Behavioral Risk Factor Surveillance System.
Participants:
A total of 13 268 adults with diabetes and 9330 adults with prediabetes (median response rate: 46.8%).
Measures:
The outcome measure was SSB intake (0, >0 to <1, and ≥1 time/day). The exposure measures were sociodemographic and behavioral characteristics.
Analysis:
Both crude and age-adjusted prevalences were calculated. Multinomial logistic regressions were used to estimate the adjusted prevalence ratio (PR) for SSB intake by participants’ characteristics.
Results:
In 2013, 22.0% adults with diabetes and 38.2% adults with prediabetes consumed SSBs ≥1 time/day. Among adults with diabetes, adjusted PR for consuming SSBs ≥1 time/day was significantly greater for those who had shorter duration of diabetes (≤5 years: PR = 1.47; 6–10 years: PR = 1.33 vs ≥11 years), less frequently self-checking blood sugar (≥0 to <1 time/day: PR = 1.69; ≥1 to <3 times/day: PR = 1.43 vs ≥3 times/day), and no self-management of diabetes course taken (PR = 1.25 vs yes). Among adults with prediabetes, testing blood sugar ≤3 years was not associated with consuming SSBs≥1 time/day.
Conclusion:
Daily SSB intake was associated with various characteristics among adults with diabetes or prediabetes. The findings can inform efforts to decrease SSB intake among high-risk populations.
Keywords: sugar-sweetened beverage (SSB), diabetes, prediabetes, nutrition, population health
Purpose
Diabetes is a major public health issue in the United States. In 2015, 9.4% of US adults aged ≥18 years had diagnosed or undiagnosed diabetes. An additional 33.9% had prediabetes and are at an increased risk of developing diabetes in the future.1 Diabetes places a huge burden on the US economy, with total costs attributable to diabetes estimated to be $245 billion in 2012.2 Although recent data suggest that the overall diabetes incidence may be nonincreasing, it continues to increase among certain demographic subpopulations.3
Frequent intake of sugar-sweetened beverages (SSBs) is associated with numerous adverse health consequences,4–16 which may be more critical among adults with elevated blood glucose levels. Sugar-sweetened beverages contribute substantial amounts of added sugars to the diet of US adults,17 which should be limited to <10% of calories from these added sugars.18 Despite medical advice of limiting sugar intake given to people with diagnosed diabetes or prediabetes, 45% of US adults with diabetes reported drinking SSBs on a surveyed day in 2003 to 2006.19 Sugar-sweetened beverage intake among the US adult population has been well studied.20–23 However, SSB intake patterns among US adults with diabetes or prediabetes are unknown. Identifying high-risk groups among those with diabetes or prediabetes could inform targeted intervention efforts to reduce complications in this population. Therefore, the objectives of this study were to examine the associations between sociodemographic and behavioral characteristics and SSB intake and to explore the relationship between diabetes- or prediabetes-related behaviors and SSB intake among adults with diabetes or prediabetes using state-based survey data.
Methods
Design
This cross-sectional study used data from the 2013 Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS is the world’s largest ongoing random-digit-dialed telephone survey that collects health information from noninstitutionalized US adults age ≥18 years. In 2013, the median response rate24 from the states that participated in the SSB and diabetes or prediabetes modules was 46.8%, ranging from 36.2% in District of Columbia (DC) to 55.7% in Kentucky.25 The study was deemed exempt by the Centers for Disease Control and Prevention Institutional Review Board.26
Sample
For current analyses, 3 mutually exclusive study populations were included: adults with diabetes, adults with prediabetes, and adults without diabetes or prediabetes. Diabetes was defined as respondents answering “yes” to the question in the core section, “Have you ever been told you have diabetes?” If respondents answered “no,” they had no diabetes or prediabetes. Prediabetes was defined as respondents answering “yes” to the prediabetes module question, “Have you ever been told by a doctor or other health professional that you have prediabetes or borderline diabetes?” or answering “no, prediabetes or borderline diabetes” to the diabetes question stated above.
In 2013, 15 states (Alaska, Arizona, Connecticut, Indiana, Iowa, Kansas, Kentucky, Louisiana, Minnesota, New Jersey, North Carolina, Ohio, South Carolina, West Virginia, and Wisconsin) and DC participated in both the diabetes and SSB modules, and 16 states (15 aforementioned states excluding New Jersey and including Mississippi and Utah) and DC participated in both the prediabetes and SSB modules. Adults without diabetes or prediabetes were selected from the 17 states and DC that participated in SSB and diabetes or prediabetes modules.
Measures
The outcome variable was SSB intake. In 2013, BRFSS included an optional module with 2 SSB intake questions: (1) During the past 30 days, how often do you drink regular soda or pop that contains sugar? Do not include diet soda or diet pop, and (2) during the past 30 days, how often did you drink sugar-sweetened fruit drinks (such as Kool-Aid and lemonade), sweet tea, and sports or energy drinks (such as Gatorade and Red Bull)? Do not include 100% fruit juice, diet drinks, or artificially sweetened drinks. For each question, respondents reported the number of times per day, week, or month they drank SSBs. Weekly or monthly intake was converted to daily consumption. To calculate the total SSB intake frequency, both questions were summed. The frequencies were grouped into 3 categories: 0, >0 to <1, and ≥1 time/day.
The explanatory variables were sociodemographic and behavioral characteristics. Sociodemographic variables included age at interview (18–44, 45–64, and ≥65 years), sex, race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanics, non-Hispanic American Indian or Alaskan Native, non-Hispanic Asian, non-Hispanic Native Hawaiian or other Pacific Islander or non-Hispanic others, and non-Hispanic muitiracial group), education (<high school, high school graduate, some college, and ≥college graduate), marital status (married and not married [single/divorced/separated/widowed]), and weight status (underweight/normal weight, overweight, and obese).27 Health-risk behavioral variables included cigarette smoking status (nonsmoker, former smoker, and current smoker)28 and alcohol drinking status28 (no drinking, any drinking, and heavy drinking). Nonsmokers were defined as respondents not having had smoked ≥100 cigarettes in their lifetime. Former smokers were defined as respondents having had smoked ≥100 cigarettes in their lifetime and currently not smoking. Current smokers were defined as respondents having smoked ≥100 cigarettes in their lifetime and currently smoking every day or some days. Any drinking was defined as 1 drink of any alcoholic beverage during the past month but not heavy drinking. Heavy drinking was defined as ≥2 drinks/day on average for men or ≥1 drink/day on average for women.28 Additional health-risk behavioral variables included meeting recommended consumption of fruits and vegetables defined based on a previously developed scoring algorithms29 and physical activity28 (moderate intensity equivalent aerobic physical activity 0, 1–149, and ≥150 min/wk).
For adults with diabetes, 3 diabetes-related variables included were whether or not having taken a self-management course on diabetes, duration of diabetes (subtracting respondents’ reported age when diabetes was diagnosed from their age at interview), and self-checking blood sugar defined as a daily frequency (<1, 1-<3, and ≥3 times/day). Duration of diabetes was categorized into ≤5, 6 to 10, and ≥11 years. For adults with prediabetes, the only prediabetes-related variable was defined as respondents having had a test for high blood sugar or diabetes within the past 3 years.
Analysis
The analytic sample included 3 subpopulations (13 268 adults with diabetes, 9330 adults with prediabetes, and 100 241 adults without diabetes or prediabetes). For unadjusted analysis, χ2 tests were used to examine the associations between respondents’ characteristics and SSB intake. A multinomial logistic regression with a generalized logit link was constructed to generate prevalence ratios (PRs) of daily SSB intake to compare the prevalence of SSB intake in each level of characteristics with its reference category, adjusting for age. Analyses were conducted separately for 3 subpopulations. For behavioral variables related to diabetes or prediabetes, age-adjusted prevalence of SSB intake was calculated using the 2000 projected US population.30 To test the associations between the behavioral variables and SSB intake, a multinomial logistic regression was constructed adjusting for all covariates. SAS Callable SUDAAN 11.0.1 (Research Triangle Institute, Research Triangle Park, North Carolina) was used to perform all analyses accounting for the complex sampling design.
Results
Of the 13 268 adults with diabetes, crude prevalence of SSB intake ≥1 time/day was 16.3%. Those who had significantly higher PR for drinking SSBs ≥1 time/day were younger, non-Hispanic black or American Indian or Alaskan Native, less educated, not married, current smokers, or those reported no physical activity compared to their counterparts (Table 1).
Table 1.
The Association Between Selected Characteristics of Respondents and SSB Intake Among Adults With Diabetes in 15 States and District of Columbia, Behavioral Risk Factor Surveillance System, 2013.a
| SSB Intake (Time/day) | |||||||
|---|---|---|---|---|---|---|---|
| Prevalence, % (95% CI) | Prevalence Ratiob (95% CI) | ||||||
| Characteristics | Weighted % | 0 | >0 to <1 | ≥1 | 0 | >0 to <1 | ≥1 |
| All respondents with diabetes (n = 13 268) | 100 | 50.3 (48.6–52.0) | 33.4 (31.9–35.0) | 16.3 (15.1–17.5) | – | – | – |
| Age | |||||||
| 18–44 years | 11.6 | 33.8 (28.8–39.1) | 38.4 (32.8–44.3) | 27.9 (23.1–33.3) | 0.59 (0.50–0.69) | 1.28 (1.08–1.51) | 2.42 (1.81–2.77) |
| 45–64 years | 45.2 | 47.7 (45.1–50.3) | 35.4 (33.0–37.9) | 16.9 (15.0–19.0) | 0.83 (0.78–0.89) | 1.18 (1.07–1.30) | 1.36 (1.16–1.60) |
| ≥65 years | 43.2 | 57.5 (55.3–59.8) | 30.0 (28.1–32.1) | 12.4 (11.1–13.9) | 1.00 | 1.00 | 1.00 |
| Sex | |||||||
| Men | 48.6 | 49.1 (46.5–51.7) | 33.4 (31.0–35.8) | 17.5 (15.7–19.6) | 0.96 (0.90–1.03) | 0.99 (0.90–1.09) | 1.15 (0.99–1.33) |
| Women | 51.4 | 51.5 (49.3–53.7) | 33.5 (31.5–35.5) | 15.0 (13.6–16.6) | 1.00 | 1.00 | 1.00 |
| Race/ethnicityc (n = 13 081) | |||||||
| Non-Hispanic white | 72.6 | 55.2 (53.4–56.9) | 30.6 (29.0–32.2) | 14.3 (13.0–15.6) | 1.00 | 1.00 | 1.00 |
| Non-Hispanic black | 15.7 | 29.8 (26.2–33.6) | 46.9 (42.9–51.0) | 23.3 (20.2–26.8) | 0.56 (0.49–0.63) | 1.51 (1.37–1.68) | 1.57 (1.32–1.86) |
| Hispanics | 6.7 | 47.6 (38.1–57.4) | 32.1 (24.0–41.4) | 20.3 (13.5–29.3) | 0.93 (0.77–1.12) | 1.00 (0.76–1.33) | 1.24 (0.65–1.53) |
| Non-Hispanic American Indian or Alaskan Native | 1.5 | 33.9 (22.7–47.2) | 34.9 (23.3–48.7) | 31.2 (18.9–47.0) | 0.67 (0.47–0.96) | 1.12 (0.77–1.62) | 1.97 (1.20–3.23) |
| Non-Hispanic multiracial group | 1.0 | 46.6 (31.4–62.5) | 43.2 (28.3–59.5) | d | 0.92 (0.66–1.27) | 1.33 (0.90–1.97) | d |
| Education (n = 13 241) | |||||||
| <High school | 20.1 | 44.4 (39.9–49.1) | 30.8 (26.8–35.1) | 24.8 (21.1–28.9) | 0.75 (0.67–0.84) | 0.95 (0.80–1.12) | 2.88 (2.20–3.76) |
| High school graduate | 34.0 | 50.1 (47.6–52.7) | 33.6 (31.2–36.0) | 16.3 (14.5–18.3) | 0.85 (0.78–0.91) | 1.04 (0.92–1.17) | 1.91 (1.51–2.43) |
| Some college | 29.1 | 50.0 (46.9–53.2) | 35.5 (32.5–38.6) | 14.5 (12.6–16.7) | 0.86 (0.79–0.94) | 1.08 (0.94–1.23) | 1.64 (1.28–2.11) |
| College graduate | 16.8 | 58.2 (54.6–61.8) | 32.9 (29.6–36.4) | 8.9 (7.2–11.0) | 1.00 | 1.00 | 1.00 |
| Marital status (n = 13 222) | |||||||
| Married | 55.2 | 53.7 (51.3–56.1) | 32.5 (30.2–34.7) | 13.9 (12.3–15.5) | 1.00 | 1.00 | 1.00 |
| Not married | 44.8 | 46.2 (44.0–48.5) | 34.5 (32.3–36.8) | 19.3 (17.4–21.3) | 0.87 (0.82–0.93) | 1.06 (0.97–1.16) | 1.36 (1.17–1.58) |
| Weight status (n = 12 669) | |||||||
| Underweight/normal weight (BMI <25 kg/m2) | 14.4 | 56.1 (51.2–60.8) | 26.7 (22.8–31.1) | 17.2 (14.1–20.9) | 1.00 | 1.00 | 1.00 |
| Overweight (BMI 25–<30 kg/m2) | 29.7 | 51.6 (48.5–54.8) | 33.7 (30.6–36.8) | 14.7 (12.8–16.8) | 0.92 (0.82–1.02) | 1.26 (1.05–1.50) | 0.86 (0.68–1.10) |
| Obese (BMI ≥30 kg/m2) | 55.9 | 47.7 (45.5–50.0) | 35.3 (33.2–37.4) | 17.0 (15.3–18.9) | 0.88 (0.80–0.98) | 1.28 (1.09–1.52) | 0.93 (0.74–1.16) |
| Smoking (n = 13 208) | |||||||
| Nonsmoker | 45.8 | 51.1 (48.5–53.6) | 35.1 (32.7–37.5) | 13.9 (12.4–15.5) | 1.00 | 1.00 | 1.00 |
| Former smoker | 37.1 | 54.6 (52.0–57.2) | 31.7 (29.4–34.2) | 13.7 (12.0–15.63) | 1.04 (0.97–1.11) | 0.93 (0.84–1.02) | 1.05 (0.88–1.24) |
| Current smoker | 17.1 | 39.0 (35.0–43.1) | 32.8 (28.9–37.0) | 28.2 (24.2–32.6) | 0.81 (0.72–0.90) | 0.91 (0.79–1.06) | 1.94 (1.61–2.33) |
| Alcohol drinking (n = 13 083) | |||||||
| No drinking | 68.2 | 50.8 (48.8–52.8) | 32.0 (30.2–33.9) | 17.2 (15.8–18.7) | 1.00 | 1.00 | 1.00 |
| Any drinking | 29.5 | 49.6 (46.3–53.0) | 37.1 (34.1–40.3) | 13.3 (11.1–15.7) | 1.00 (0.93–1.08) | 1.14 (1.03–1.27) | 0.74 (0.61–0.90) |
| Heavy drinking | 2.3 | 56.5 (45.5–67.0) | 25.8 (17.8–35.8) | 17.6 (9.9–29.4) | 1.16 (0.96–1.40) | 0.78 (0.55–1.12) | 0.95 (0.53–1.67) |
| Met fruit intake guideline | |||||||
| Yes | 7.5 | 52.7 (46.6–58.6) | 31.7 (26.4–37.4) | 15.7 (11.7–20.6) | 1.00 | 1.00 | 1.00 |
| No | 92.5 | 50.1 (48.4–51.9) | 33.6 (31.9–35.2) | 15.7 (11.7–20.6) | 0.94 (0.84–1.05) | 1.07 (0.89–1.28) | 1.08 (0.81–1.44) |
| Met vegetable intake guideline | |||||||
| Yes | 4.4 | 65.6 (59.1–71.5) | 20.3 (15.9–25.5) | 14.1 (10.0–19.6) | 1.00 | 1.00 | 1.00 |
| No | 95.6 | 49.6 (17.9–51.4) | 34.0 (32.4–35.7) | 16.4 (15.1–17.7) | 0.74 (0.67–0.81) | 1.75 (1.36–2.24) | 1.24 (0.89–1.73) |
| Physical activity (n = 12 774) | |||||||
| 0 min/wk | 43.9 | 48.7 (46.0–51.4) | 32.0 (29.6–34.5) | 19.3 (17.3–21.5) | 0.89 (0.82–0.95) | 0.99 (0.88–1.11) | 1.49 (1.26–1.78) |
| 1–149 min/wk | 17.7 | 45.4 (41.8–49.1) | 38.4 (34.9–42.0) | 16.2 (13.4–19.5) | 0.87 (0.79–0.95) | 1.16 (1.02–1.31) | 1.16 (0.92–1.46) |
| ≥150 min/wk | 38.4 | 54.2 (51.4–57.0) | 32.5 (29.9–35.2) | 13.3 (11.6–15.1) | 1.00 | 1.00 | 1.00 |
Abbreviations: BMI, body mass index; CI, confidence interval; SSB, sugar-sweetened beverage.
Boldface indicates statistical significant based on weighted χ2 test association of SSBs with demographics and behavioral factors, and age adjusted multinomial logistic regression (except for age groups), P < .05.
Multinomial logistic regression adjusted for age except for comparison for age.
Data for non-Hispanic Asian (n ꞊ 73) and non-Hispanic Native Hawaiian or other Pacific Islanders or non-Hispanic others (n ꞊ 110) were suppressed becausemost data in the SSB categories had either sample size less than 50 or relative standard error greater than 0.3.
Prevalence and prevalence ratios were suppressed for unreliable results because the sample size was less than 50 or relative standard error was greater than 0.3.
Of the 9330 adults with prediabetes, crude prevalence of SSB intake ≥1 time/day was 32.5%. Those who had significantly higher PR for drinking SSBs ≥1 time/day were younger, men, non-Hispanic black, less educated, not married, current smoker, those who did not meet vegetable intake guideline, or those who reported no physical activity compared to their counterparts (Table 2).
Table 2.
The Association Between Selected Characteristics of Respondents and SSB Intake Among Adults with Prediabetes in 16 States and District of Columbia, Behavioral Risk Factor Surveillance System, 2013.a
| SSB Intake (Time/day) | |||||||
|---|---|---|---|---|---|---|---|
| Prevalence, % (95% CI) | Prevalence Ratiob (95% CI) | ||||||
| Characteristics | Weighted % | 0 | >0 to <1 | ≥1 | 0 | >0 to <1 | ≥1 |
| All respondents with prediabetes (n = 9330) | 100 | 26.0 (24.6–27.6) | 41.5 (39.6–43.4) | 32.5 (30.6–34.3) | – | – | – |
| Age | |||||||
| 18–44 years | 30.8 | 12.1 (10.0–14.5) | 37.4 (33.4–41.6) | 50.5 (46.3–54.7) | 0.30 (0.25–0.37) | 0.91 (0.80–1.03) | 2.70 (2.31–3.15) |
| 45–64 years | 45.7 | 28.3 (26.0–30.7) | 44.4 (41.7–47.1) | 27.3 (25.0–29.7) | 0.71 (0.63–0.79) | 1.08 (0.98–1.18) | 1.46 (1.25–1.70) |
| ≥65 years | 23.5 | 40.0 (37.1–43.0) | 41.3 (38.3–44.3) | 18.7 (16.5–21.2) | 1.00 | 1.00 | 1.00 |
| Sex | |||||||
| Men | 38.7 | 24.1 (21.7–26.8) | 43.1 (40.0–46.2) | 32.8 (29.8–35.9) | 0.78 (0.69–0.88) | 1.04 (0.94–1.14) | 1.16 (1.04–1.30) |
| Women | 61.3 | 27.3 (25.4–29.2) | 40.5 (38.2–42.9) | 32.2 (29.9–34.7) | 1.00 | 1.00 | 1.00 |
| Race/ethnicityc (n = 9216) | |||||||
| Non-Hispanic white | 75.4 | 29.6 (27.8–31.4) | 39.7 (37.7–41.7) | 30.7 (28.7–32.7) | 1.00 | 1.00 | 1.00 |
| Non-Hispanic black | 15.1 | 11.9 (9.0–15.5) | 47.6 (42.0–53.3) | 40.5 (35.0–46.3) | 0.45 (0.34–0.59) | 1.23 (1.08–1.39) | 1.21 (1.04–1.40) |
| Hispanics | 5.3 | 15.9 (10.9–22.7) | 41.6 (31.7–52.3) | 42.5 (31.9–53.8) | 0.75 (0.53–1.05) | 1.11 (0.88–1.41) | 1.08 (0.82–1.44) |
| Non-Hispanic American Indian or Alaskan Native | 1.6 | d | 39.3 (26.6–53.6) | 27.1 (17.2–40.0) | d | 0.99 (0.69–1.42) | 0.82 (0.51–1.32) |
| Non-Hispanic multiracial group | 0.9 | d | 44.9 (30.5–60.3) | d | d | 1.15 (0.82–1.62) | d |
| Education (n = 9318) | |||||||
| <High school | 14.7 | 19.0 (15.0–23.9) | 36.3 (30.9–42.1) | 44.7 (39.0–50.5) | 0.58 (0.45–0.74) | 0.78 (0.66–0.93) | 2.13 (1.74–2.59) |
| High school graduate | 30.4 | 25.6 (23.1–28.3) | 40.5 (37.2–43.9) | 33.9 (30.7–37.3) | 0.76 (0.67–0.87) | 0.87 (0.77–0.97) | 1.66 (1.38–1.98) |
| Some college | 32.0 | 24.8 (22.1–27.7) | 41.1 (37.7–44.6) | 34.1 (30.7–37.6) | 0.81 (0.70–0.93) | 0.89 (0.79–1.00) | 1.54 (1.29–1.85) |
| College graduate | 23.0 | 32.9 (29.8–36.2) | 46.6 (43.0–50.2) | 20.5 (17.3–24.2) | 1.00 | 1.00 | 1.00 |
| Marital status (n = 9302) | |||||||
| Married | 56.5 | 28.0 (25.9–30.2) | 44.4 (41.8–46.9) | 27.7 (25.4–30.0) | 1.00 | 1.00 | 1.00 |
| Not married | 43.5 | 23.5 (21.4–25.7) | 37.7 (35.1–40.5) | 38.8 (35.9–41.8) | 0.91 (0.81–1.02) | 0.87 (0.79–0.95) | 1.29 (1.16–1.44) |
| Weight status (n = 8821) | |||||||
| Underweight/normal weight (BMI <25 kg/m2) | 20.8 | 28.1 (24.6–31.8) | 37.1 (32.6–41.8) | 34.9 (30.6–39.4) | 1.00 | 1.00 | 1.00 |
| Overweight (BMI 25–<30 kg/m2) | 31.7 | 26.1 (23.5–28.9) | 42.8 (39.5–46.2) | 31.1 (27.9–34.5) | 0.87 (0.74–1.02) | 1.13 (0.98–1.31) | 0.97 (0.82–1.13) |
| Obese (BMI ≥30 kg/m2) | 47.5 | 24.9 (22.7–27.2) | 42.7 (40.0–45.5) | 32.4 (29.7–35.2) | 0.89 (0.77–1.04) | 1.14 (0.99–1.31) | 0.97 (0.81–1.09) |
| Smoking (n = 9293) | |||||||
| Nonsmoker | 48.2 | 24.9 (22.8–27.1) | 45.2 (42.3–48.0) | 29.9 (27.2–32.8) | 1.00 | 1.00 | 1.00 |
| Former smoker | 29.9 | 34.8 (31.8–38.0) | 41.4 (38.2–44.8) | 23.8 (21.0–26.8) | 1.24 (1.10–1.41) | 0.92 (0.83–1.02) | 0.92 (0.79–1.06) |
| Current smoker | 21.9 | 16.7 (14.0–19.7) | 33.6 (29.8–37.6) | 49.8 (45.6–54.0) | 0.80 (0.67–0.95) | 0.77 (0.68–0.88) | 1.52 (1.34–1.72) |
| Alcohol drinking (n = 9182) | |||||||
| No drinking | 52.1 | 25.5 (23.5–27.6) | 37.9 (35.4–40.4) | 36.6 (34.0–39.3) | 1.00 | 1.00 | 1.00 |
| Any drinking | 43.1 | 26.4 (24.0–28.9) | 46.7 (43.7–49.8) | 26.9 (24.3–29.8) | 1.10 (0.97–1.23) | 1.24 (1.13–1.36) | 0.70 (0.62–0.79) |
| Heavy drinking | 4.8 | 28.2 (21.6–35.9) | 35.8 (28.4–44.1) | 36.0 (27.2–45.8) | 1.15 (0.91–1.45) | 0.95 (0.76–1.19) | 0.96 (0.76–1.20) |
| Met fruit intake guideline | |||||||
| Yes | 8.8 | 31.6 (26.9–36.8) | 40.7 (35.2–46.4) | 27.7 (21.9–34.3) | 1.00 | 1.00 | 1.00 |
| No | 91.2 | 25.5 (23.9–27.2) | 41.6 (39.6–43.6) | 32.9 (31.0–34.9) | 0.80 (0.68–0.94) | 1.02 (0.88–1.18) | 1.20 (0.97–1.49) |
| Met vegetable intake guideline | |||||||
| Yes | 5.4 | 39.8 (33.0–47.1) | 37.0 (30.1–44.5) | 23.2 (17.6–30.1) | 1.00 | 1.00 | 1.00 |
| No | 94.6 | 25.3 (23.7–26.9) | 41.8 (39.8–43.7) | 33.0 (31.1–34.9) | 0.64 (0.53–0.77) | 1.14 (0.93–1.39) | 1.39 (1.06–1.82) |
| Physical activity (n = 9063) | |||||||
| 0 min/wk | 34.3 | 22.2 (19.9–24.7) | 36.5 (33.3–39.7) | 41.4 (38.0–44.8) | 0.70 (0.61–0.79) | 0.85 (0.76–0.95) | 1.61 (1.42–1.82) |
| 1–149 min/wk | 20.5 | 21.2 (18.2–24.5) | 47.5 (43.2–51.9) | 31.3 (27.5–35.4) | 0.73 (0.62–0.86) | 1.12 (1.00–1.25) | 1.13 (0.96–1.33) |
| ≥150 min/wk | 45.2 | 31.4 (28.9–34.0) | 42.6 (39.7–45.5) | 26.0 (23.3–28.9) | 1.00 | 1.00 | 1.00 |
Abbreviations: BMI, body mass index; CI, confidence interval; SSB, sugar-sweetened beverage.
Boldface indicates statistical significant based on weighted χ2 test association of SSBs with demographics and behavioral factors, and age-adjusted multinomial logistic regression (except for age groups), P < .05.
Multinomial logistic regression adjusted for age except for comparison for age.
Data for non-Hispanic Asian (n ꞊ 73) and non-Hispanic Native Hawaiian or other Pacific Islanders or non-Hispanic others (n = 110) were suppressed because most data in the SSB categories had either sample size less than 50 or relative standard error greater than 0.3.
Prevalence and prevalence ratios were suppressed for unreliable results because the sample size was less than 50 or relative standard error was greater than 0.3.
Of the 100 241 adults without diabetes or prediabetes, crude prevalence of SSB intake ≥1 time/day was 34.1%. Those who had significantly higher PR for drinking SSBs ≥1 time/day were younger, men, non-Hispanic black, Hispanics, non-Hispanic American Indian or Alaskan Native, non-Hispanic multiracial group, less educated, not married, obese, current smokers, those who failed to meet fruits or vegetable intake guidelines, or those reported no physical activities compared to their counterparts (Table 3).
Table 3.
The Association Between Selected Characteristics of Respondents and SSB Intake Among Adults Without Diabetes or Prediabetes in 17 States and District of Columbia, Behavioral Risk Factor Surveillance System, 2013.a
| SSB Intake (Time/day) | |||||||
|---|---|---|---|---|---|---|---|
| Prevalence, % (95% CI) | Prevalence Ratiob (95% CI) | ||||||
| Characteristics | Weighted % | 0 | >0 to <1 | ≥1 | 0 | >0 to <1 | ≥1 |
| All respondents without diabetes or prediabetes (n = 100 241) | 100 | 22.2 (21.7–22.6) | 43.7 (43.1–44.3) | 34.1 (33.5–34.7) | – | – | – |
| Age | |||||||
| 18–44 years | 48.4 | 12.1 (11.5–12.7) | 45.2 (44.2–46.2) | 42.7 (41.7–43.7) | 0.32 (0.31–0.34) | 1.07 (1.03–1.10) | 2.10 (1.99–2.21) |
| 45–64 years | 34.8 | 29.0 (28.2–29.9) | 42.2 (41.3–43.1) | 28.7 (27.9–29.6) | 0.78 (0.75–0.81) | 1.00 (0.96–1.03) | 1.41 (1.33–1.49) |
| ≥65 years | 16.8 | 37.2 (36.1–38.3) | 42.4 (41.3–43.5) | 20.4 (19.4–21.3) | 1.00 | 1.00 | 1.00 |
| Sex | |||||||
| Men | 48.6 | 16.0 (15.4–16.6) | 43.8 (42.9–44.7) | 40.2 (39.3–41.2) | 0.60 (0.57–0.63) | 1.00 (0.97–1.03) | 1.38 (1.33–1.43) |
| Women | 51.4 | 28.0 (27.4–28.7) | 43.6 (42.8–44.4) | 28.3 (27.6–29.1) | 1.00 | 1.00 | 1.00 |
| Race/ethnicity (n = 99 062) | |||||||
| Non-Hispanic white | 76.1 | 25.1 (24.5–25.6) | 43.0 (42.4–43.7) | 31.9 (31.3–32.6) | 1.00 | 1.00 | 1.00 |
| Non-Hispanic black | 11.3 | 9.1 (8.2–10.1) | 43.8 (41.8–45.8) | 47.1 (45.1–49.1) | 0.42 (0.38–0.47) | 1.03 (0.98–1.08) | 1.39 (1.32–1.45) |
| Hispanics | 7.7 | 13.1 (11.4–15.1) | 46.8 (43.9–49.7) | 40.1 (37.1–43.1) | 0.71 (0.62–0.81) | 1.09 (1.02–1.16) | 1.10 (1.02–1.19) |
| Non-Hispanic American Indian or Alaskan Native | 0.9 | 15.6 (12.3–19.6) | 37.0 (31.3–43.1) | 47.4 (41.2–53.7) | 0.72 (0.58–0.88) | 0.86 (0.73–1.01) | 1.39 (1.22–1.59) |
| Asian | 2.3 | 27.6 (22.8–32.9) | 55.6 (49.9–61.1) | 16.8 (13.0–21.5) | 1.38 (1.17–1.62) | 1.21 (1.09–1.35) | 0.44 (0.34–0.57) |
| Native Hawaii or Pacific Islanders or others | 0.6 | 20.5 (15.6–26.5) | 52.9 (44.4–61.3) | 26.5 (20.0–34.3) | 0.93 (0.73–1.18) | 1.21 (1.03–1.43) | 0.77 (0.59–1.01) |
| Non-Hispanic multiracial group | 1.0 | 13.4 (10.4–17.0) | 44.6 (38.4–51.0) | 42.0 (36.1–48.1) | 0.64 (0.51–0.82) | 1.04 (0.90–1.20) | 1.21 (1.04–1.41) |
| Education (n = 100 036) | |||||||
| <High school | 12.4 | 14.0 (12.7–15.4) | 34.9 (32.9–37.0) | 51.1 (48.9–53.3) | 0.46 (0.41–0.50) | 0.68 (0.64–0.72) | 2.83 (2.66–3.00) |
| High school graduate | 29.9 | 19.7 (18.9–20.5) | 38.7 (37.7–39.8) | 41.5 (40.4–42.7) | 0.62 (0.59–0.65) | 0.76 (0.73–0.78) | 2.34 (2.23–2.46) |
| Some college | 31.6 | 20.5 (19.7–21.4) | 45.7 (44.6–46.9) | 33.7 (32.7–34.8) | 0.69 (0.66–0.73) | 0.89 (0.86–0.92) | 1.82 (1.73–1.92) |
| College graduate | 26.1 | 30.7 (29.9–31.6) | 51.2 (50.2–52.1) | 18.1 (17.4–18.9) | 1.00 | 1.00 | 1.00 |
| Marital status (n = 99 741) | |||||||
| Married | 53.8 | 26.3 (25.6–26.9) | 45.3 (44.5–46.1) | 28.4 (27.7–29.1) | 1.00 | 1.00 | 1.00 |
| Not married | 46.2 | 17.4 (16.8–18.0) | 41.8 (40.8–42.7) | 40.8 (39.9–41.8) | 0.78 (0.75–0.81) | 0.91 (0.88–0.93) | 1.33 (1.28–1.37) |
| Weight status (n = 95 561) | |||||||
| Underweight/normal weight (BMI <25 kg/m2) | 37.6 | 23.2 (22.4–24.0) | 43.4 (42.3–44.4) | 33.4 (32.4–34.4) | 1.00 | 1.00 | 1.00 |
| Overweight (BMI 25–<30 kg/m2) | 36.0 | 22.7 (21.9–23.5) | 44.6 (43.5–45.6) | 32.8 (31.8–33.8) | 0.90 (0.85–0.94) | 1.04 (1.00–1.07) | 1.03 (0.99–1.07) |
| Obese (BMI ≥30 kg/m2) | 26.4 | 19.5 (18.7–20.4) | 43.6 (42.4–44.8) | 36.9 (35.7–38.0) | 0.80 (0.76–0.85) | 1.01 (0.98–1.05) | 1.13 (1.08–1.18) |
| Smoking (n = 99 784) | |||||||
| Nonsmoker | 55.7 | 22.1 (21.5–22.8) | 47.9 (47.1–48.8) | 29.9 (29.1–30.7) | 1.00 | 1.00 | 1.00 |
| Former smoker | 23.9 | 30.0 (29.0–31.0) | 43.7 (42.6–44.8) | 26.3 (25.3–27.4) | 1.12 (1.07–1.17) | 0.94 (0.91–0.97) | 1.01 (0.96–1.05) |
| Current smoker | 20.4 | 13.0 (12.2–13.9) | 32.2 (31.0–33.5) | 54.8 (53.4–56.1) | 0.62 (0.58–0.67) | 0.68 (0.65–0.71) | 1.82 (1.75–1.88) |
| Alcohol drinking (n = 98 601) | |||||||
| No drinking | 47.2 | 21.2 (20.5–21.8) | 40.4 (39.5–41.3) | 38.5 (37.6–39.4) | 1.00 | 1.00 | 1.00 |
| Any drinking | 47.1 | 22.9 (22.3–23.6) | 47.3 (46.4–48.2) | 29.8 (29.0–30.6) | 1.16 (1.11–1.21) | 1.17 (1.04–1.20) | 0.75 (0.72–0.77) |
| Heavy drinking | 5.7 | 25.8 (23.8–27.9) | 42.7 (40.3–45.2) | 31.5 (29.1–33.9) | 1.33 (1.22–1.44) | 1.05 (0.99–1.12) | 0.78 (0.72–1.84) |
| Met fruit intake guideline | |||||||
| Yes | 9.5 | 30.1 (28.5–31.8) | 42.9 (41.0–44.9) | 26.9 (25.1–28.9) | 1.00 | 1.00 | 1.00 |
| No | 90.5 | 21.4 (20.9–21.8) | 43.8 (43.1–44.4) | 34.9 (34.2–35.5) | 0.71 (0.67–0.75) | 1.02 (0.97–1.07) | 1.29 (1.20–1.38) |
| Met vegetable intake guideline | |||||||
| Yes | 5.9 | 39.2 (36.9–41.4) | 38.9 (36.7–41.2) | 21.9 (19.9–24.1) | 1.00 | 1.00 | 1.00 |
| No | 94.1 | 21.1 (20.7–21.6) | 44.0 (43.4–44.6) | 34.9 (34.3–35.5) | 0.55 (0.52–0.58) | 1.12 (1.06–1.19) | 1.57 (1.43–1.73) |
| Physical activity (n = 97 214) | |||||||
| 0 min/wk | 50.2 | 18.2 (17.4–19.0) | 37.7 (36.6–38.8) | 44.1 (43.0–45.3) | 0.67 (0.64–0.71) | 0.83 (0.80–0.86) | 1.54 (1.48–1.60) |
| 1–149 min/wk | 21.7 | 18.9 (17.9–19.9) | 48.6 (47.2–50.0) | 32.6 (31.3–33.9) | 0.82 (0.78–0.87) | 1.07 (1.03–1.11) | 1.04 (0.99–1.10) |
| ≥150 min/wk | 28.0 | 25.7 (25.0–26.4) | 45.0 (44.2–45.9) | 29.3 (28.4–30.1) | 1.00 | 1.00 | 1.00 |
Abbreviations: BMI, body mass index; CI, confidence interval; SSB, sugar-sweetened beverage.
Boldface indicates statistical significant based on weighted χ2 test association of SSBs with demographics and behavioral factors, and age-adjusted multinomial logistic regression (except for age groups), P < .05.
Multinomial logistic regression adjusted for age except for comparison for age.
The age-adjusted prevalence of consuming SSBs ≥1 time/day was 34.7% among adults without diabetes or prediabetes (data not shown) and 22.0% among adults with diabetes (Table 4). Those who were more likely to have SSBs ≥1 time/day were adults who had shorter duration of diabetes (PR = 1.47 [≤5 years] and PR = 1.33 [6–10 years] vs ≥11 years), selfchecked blood sugar less frequently (PR = 1.69 [<1 time/day] and PR = 1.43 [≥1 to <3 times/day] vs ≥3 time/day), and took a diabetes self-management course (PR = 1.25 vs no). Among adults with prediabetes, 38.2% of respondents reported consuming SSBs ≥1 time/day after age adjustment. The prevalence of no SSBs intake was lower among those who did not have a blood sugar test within the past 3 years compared with those who had a test (PR = 0.84; Table 4).
Table 4.
Age Standardized Daily SSB Intake by Characteristics of Adults With Diabetes or Prediabetes and Model Adjusted Prevalence Ratio of Consuming SSB by Characteristics Among Adults With Diabetes or Prediabetes, Behavioral Risk Factor Surveillance System, 2013.a
| SSB Intake (Time/day) | |||||||
|---|---|---|---|---|---|---|---|
| Age-Standardized Analysisb | Multinomial Logistic Regressionc | ||||||
| Prevalence, % (95% CI) | Adjusted Prevalence Ratio (95% CI) | ||||||
| Characteristics | Weighted % | 0 | >0 to <1 | ≥1 | 0 | >0 to <1 | ≥1 |
| Adults with diabetes | 42.0 (39.1–44.9) | 36.0 (33.0–39.3) | 22.0 (19.3–24.9) | n = 11 072e | |||
| Duration of diabetesd (n = 12 487) | |||||||
| <5 years | 43.3 | 35.7 (31.9–39.6) | 37.7 (32.9–42.7) | 26.6 (22.4–31.4) | 0.81 (0.74–0.88) | 1.15 (1.03–1.29) | 1.47 (1.23–1.75) |
| 6–10 years | 23.0 | 41.8 (36.1–47.7) | 36.5 (30.3–43.3) | 21.7 (16.5–28.1) | 0.89 (0.82–0.97) | 1.06 (0.94–1.20) | 1.33 (1.09–1.63) |
| ≥11 years | 33.7 | 51.9 (46.2–57.6) | 34.3 (29.1–39.9) | 13.8 (10.9–17.3) | 1.00 | 1.00 | 1.00 |
| Self-checking blood sugar (times/d; n = 13 020) | |||||||
| <1 | 36.2 | 33.0 (28.9–37.3) | 41.0 (35.2–47.0) | 26.1 (21.4–31.4) | 0.72 (0.660–0.80) | 1.29 (1.11–1.50) | 1.69 (1.33–2.15) |
| ≥1 to <3 | 44.9 | 42.2 (37.6–47.0) | 32.3 (27.9–37.0) | 25.5 (20.6–31.1) | 0.88 (0.82–0.96) | 1.07 (0.92–1.24) | 1.43 (I.I2-I.82) |
| ≥3 | 18.9 | 53.4 (47.8–59.0) | 33.7 (28.5–39.3) | 12.9 (9.9–17.0) | 1.00 | 1.00 | 1.00 |
| Taking self-management course on diabetes (n = 13 219) | |||||||
| Yes | 56.2 | 47.0 (43.0–50.9) | 35.5 (31.4–39.8) | 17.6 (14.7–20.9) | 1.00 | 1.00 | 1.00 |
| No | 3.8 | 34.9 (31.0–39.1) | 36.8 (32.1–41.7) | 28.3 (23.8–33.4) | 0.84 (0.79–0.91) | 1.15 (1.04–1.27) | 1.25 (1.06–1.46) |
| Adults with prediabetes | 21.7 (20.3–23.2) | 40.1 (37.8–42.5) | 38.2 (35.8–40.6) | n = 8342e | |||
| Blood sugar test within the past 3 years (n = 9330) | |||||||
| Yes | 80.6 | 22.3 (20.6–24.1) | 40.4 (37.7–43.1) | 37.4 (34.6–40.2) | 1.00 | 1.00 | 1.00 |
| No | 19.4 | 18.8 (16.2–21.8) | 39.8 (35.1–44.7) | 41.4 (36.8–46.1) | 0.84 (0.71–0.99) | 1.06 (0.94–1.19) | 1.06 (0.92–1.22) |
Abbreviation: CI, confidence interval; SSB, sugar-sweetened beverage.
Boldface indicates statistical significant based on adjusted multinomial logistic regression, P < .05.
Based on 2000 US age-standardized distribution (18–44, 45–64, ≥65 years).
Model is based on multinomial logistic regression with generalized logit function and controlled for sociodemographic, weight status, and behavioral characteristics. Age is excluded from model when duration of diabetes is a main exposure.
Age at interview minus age where diabetes was onset.
Sample sizes derived after excluding missing values from all variables from the models.
Discussion
After age adjustment, 1 in 5 adults with diabetes, 2 in 5 adults with prediabetes, and about 1 in 3 adults without diabetes or prediabetes reported consuming SSBs ≥1 time/day in our study. Frequent SSB intake is associated with a greater incidence of type 2 diabetes.31 For adults with diabetes, recommendations suggest limiting or avoiding SSB intake.32 Among adults with diabetes in the present study, certain characteristics significantly associated with SSB intake were similar to those found in adults without diabetes or prediabetes and US adult population.21,23 For example, the prevalence of daily SSB intake was higher in younger adults, non-Hispanic blacks, less-educated adults, unmarried adults, current smokers, and adults with no physical activity. Furthermore, adults with diabetes who had any alcohol intake were less likely to consume SSBs ≥1 time/day than those who had no alcohol intake in our study, whereas a previous study reported that US adults who had any or heavy alcohol intake were less likely to consume SSBs ≥1 time/day.33 Although meeting the fruit intake guideline was not associated with SSBs intake, adults with diabetes who did not meet vegetable intake guidelines were more likely to be SSB consumers and more likely to be moderate-SSB consumers in our study. Although a direct comparison cannot be made due to different measurements of fruit and vegetable intake. Park et al reported that adults who consumed fruit (excluding 100% juice) <1 time/day had 37% higher odds of drinking SSBs ≥1 time/day than those who consumed fruit ≥1time/day, whereas vegetable intake was not associated with daily SSBs intake.33
No study has assessed how duration of diabetes and self-management is associated with SSBs intake. In our study, there was an inverse dose response between duration of diabetes and the likelihood of consuming SSBs ≥1 time/day among adults with diabetes. Self-management of diabetes is critical to maintaining a healthy lifestyle and to control blood glucose.34 The present study showed a significant inverse dose response between the frequency of self-checking blood sugar and the likelihood of consuming SSB ≥1 time/day. Self-monitoring blood glucose levels are important for diabetes control.34 Our results suggest that the poor self-management of diabetes may be related to unhealthy lifestyle behaviors that includes daily SSB intake. Moreover, self-management education for adults with diabetes was shown to be effective to lower hemoglobin.35 Our findings showed that adults with diabetes who did not take a self-management course on diabetes were 25% more likely to consume SSBs ≥1 time/day. Although no causal relationship can be drawn from a cross-sectional study, educational diabetes self-management training focused on reducing SSB intake may be a useful resource for people with diabetes.36
Characteristics associated with daily SSB intake among adults with prediabetes was somewhat similar to that found among adults without diabetes or prediabetes and US adult population,21,33 such as younger age, being men or non-Hispanic black, less educated, not married, current smoking, not meeting vegetable intake recommendation, and no physical activity. Additionally, adults with prediabetes who did not have a blood sugar test within the past 3 years were 16% less likely to be non-SSB consumers than those who did in the present study. In 2009 to 2012, 1 of 3 adults had prediabetes and a majority of them were undiagnosed.1 The prevalence of prediabetes among adults with normal weight increased from 10.2% in 1988 to 1994 to 18.5% in 2012.37 Individuals with prediabetes have increased risk of developing diabetes, heart disease, and stroke.1 Moreover, frequent intake of SSBs has been linked to diabetes,4–6 obesity,6–8 and cardiovascular disease,6,9–11 thus limiting SSB intake among adults with prediabetes could be one of the strategies for reducing risk of adverse health consequences.
Our study has several limitations. First, BRFSS is self-reported; therefore, it may be subject to reporting and recall bias. Second, only 16 or 17 states used the diabetes or prediabetes module and SSB module; thus, results may not generalize to the entire US adult population. Third, this study only included those with diagnosis of diabetes or prediabetes that was based on self-reported medical diagnoses and not confirmed by medical records. Fourth, BRFSS does not differentiate types of diabetes. However, the prevalence is much higher in type 2 diabetes than type 1 diabetes among US adults. Lastly, BRFSS measured SSB consumption by frequency of intake; thus, the volume of SSBs consumed could not be estimated.
In conclusion, 1 in 5 and almost 2 in 5 adults with diabetes or prediabetes, respectively, consumed SSB at least once daily. Certain subpopulations (eg, non-Hispanic blacks, or adults not married or with less education) had higher prevalence of daily SSBs intake and several health-related (eg, current smoking or no physical activity) or disease-related behaviors (eg, less frequency of self-checking blood sugar) were associated with daily SSBs intake. Efforts for diabetes prevention and self-management should consider addressing the high prevalence of daily SSB intake among these high-risk populations.
SO WHAT?
Implication for Health Promotion Practitioners and Researchers
What is already known on the topic?
Frequent sugar-sweetened beverage (SSB) intake is associated with many adverse health consequences including diabetes. Among the US adult population, 30.1% consumed SSB ≥1 time/day. While SSB intake among the US adult population has been well studied, SSB intake patterns among US adults with diabetes or prediabetes are unknown.
What does the article add?
Overall, 22.0% adults with diabetes, 38.2% adults with prediabetes, and 34.7% adults without diabetes or prediabetes consumed SSB ≥1 time/day. Daily SSB intake was associated with various sociodemographic and disease-related behavioral characteristics. Sugar-sweetened beverage intake ≥1 time/day declined with increasing age and educational level and was higher among non-Hispanic blacks, being not married, current smokers, those with no physical activity, those with shorter duration of diabetes, those who did not check blood sugar frequently, and those who did not take self-management of diabetes course.
What are the implications for health promotion practice or research?
Daily SSB intake is somewhat prevalent among adults with diabetes, and the prevalence is especially high among adults with prediabetes. Although diabetes self-management education that emphasizes limiting SSB intake may be useful to individuals at risk of developing diabetes, education alone may not be sufficient for behavior change. Understanding barriers to reducing SSB intake could help in designing intervention efforts to decrease SSB intake among these high-risk populations.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Footnotes
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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