Cited by 436Diet, Metabolism, and DiseaseObesity, Physical Activity, DietDiabetes, Cardiovascular Risks, and Lipoproteins

The DOI matches its Crossref record; 43 of the 43 references it cites were found in a registry or an index; 2 of the 25 sources its claims cite were checked for support.

The Relationship of Sugar to Population-Level Diabetes Prevalence: An Econometric Analysis of Repeated Cross-Sectional Data

Open access

Abstract

While experimental and observational studies suggest that sugar intake is associated with the development of type 2 diabetes, independent of its role in obesity, it is unclear whether alterations in sugar intake can account for differences in diabetes prevalence among overall populations. Using econometric models of repeated cross-sectional data on diabetes and nutritional components of food from 175 countries, we found that every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with increased diabetes prevalence by 1.1% (p <0.001) after testing for potential selection biases and controlling for other food types (including fibers, meats, fruits, oils, cereals), total calories, overweight and obesity, period-effects, and several socioeconomic variables such as aging, urbanization and income. No other food types yielded significant individual associations with diabetes prevalence after controlling for obesity and other confounders. The impact of sugar on diabetes was independent of sedentary behavior and alcohol use, and the effect was modified but not confounded by obesity or overweight. Duration and degree of sugar exposure correlated significantly with diabetes prevalence in a dose-dependent manner, while declines in sugar exposure correlated with significant subsequent declines in diabetes rates independently of other socioeconomic, dietary and obesity prevalence changes. Differences in sugar availability statistically explain variations in diabetes prevalence rates at a population level that are not explained by physical activity, overweight or obesity.

Overview

AI snapshot

Written from the paper’s full text.

TL;DR

Using econometric models of repeated cross-sectional data from 175 countries, this study found that higher sugar availability was associated with higher population-level diabetes prevalence, independent of obesity and other food types. The author concludes that sugar availability statistically explains some population variation in diabetes rates not explained by physical activity, overweight, or obesity.

Key findings

  • Every 150 kcal/person/day increase in sugar availability (about one can of soda/day) was associated with a 1.1% increase in diabetes prevalence (95% CI: 0.48–1.7%; p<0.001) after controlling for other foods, total calories, overweight/obesity, period effects, and socioeconomic variables; total calorie availability was not significantly associated (0.1% rise per 150 kcal, not significant). No other food type had a significant individual association with diabetes prevalence after controls.
  • The fraction of total calories from sugar was the only significant food fraction: a 1% rise corresponded to a 0.167% rise in diabetes prevalence. Each extra year of high sugar availability (≥300 kcal/person/day) was associated with a 0.053% increase in diabetes prevalence (p<0.05), and periods after a country lowered sugar availability showed a 0.074% reduction in diabetes prevalence (p<0.05).
  • Diabetes prevalence rose 27% on average from 2000 to 2010, with just over one-fourth of the increase explained by rising sugar availability in the model. The sugar association remained after controlling for selection bias (magnified to 1.2% per 150 kcal/person/day, p<0.001), after removing outliers (1.2%, p<0.001), and in an autoregressive time-series model (0.4%, p<0.001).

Methods

  • Econometric analysis of repeated cross-sectional panel data from 175 countries, 2000–2010. Diabetes prevalence (ages 20–79) came from the International Diabetes Federation; sugar and other food availability (kcal/person/day) came from UN FAO food supply data.
  • Main models controlled for total calories, fibers, fruits, meats, cereals, oils, log GDP per capita, change in log GDP, urbanization, aging, obesity/overweight, period effects, and later physical inactivity, smoking, and heavy alcohol use. Food data were age-adjusted, regressions were population weighted, and robust standard errors were used.
  • Analyses included Generalized Estimating Equations for model selection, a Hausman test, a Heckman-type selection model for high sugar availability, Granger-causality tests, and robustness checks (outlier removal, autoregressive time-series, fixed effects, direct survey data, and excluding the U.S.).

Limitations

  • The paper states that cross-country ecological analysis risks ecological fallacy; food supply data measure availability, not actual consumption, and cannot account precisely for food wastage. It also cannot distinguish specific added sugars (e.g., HFCS vs. sucrose) or specific vehicles (e.g., soda vs. processed food).
  • The paper states that ecological data limit statistical power and lose age, sex, and racial predictions; IDF diabetes prevalence data come from surveys of varying quality, likely underestimate diabetes, and do not distinguish type 1 from type 2 diabetes. FAO, IDF, and WHO data are described as imperfect, making findings exploratory.
  • Evident from the text: the study is observational and country-level, so it cannot establish individual-level causation; despite extensive controls, unmeasured confounding remains possible, and sugar availability is a proxy for intake rather than a direct consumption measure.

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Integrity signals

Registry

Crossref · 10.1371/journal.pone.0057873

Cites

43 of 43 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Figures

Figure 1 Relationship between obesity and diabetes prevalence rates worldwide. Obesity prevalence is defined as the percentage of the population aged 15 to 100 years old with body mass index greater than or equal to 30 kg/meters squared, from the World Health Organization Global Infobase 2012 edition. Diabetes prevalence is defined as the percentage of the population aged 20 to 79 years old with diabetes, from the International Diabetes Federation Diabetes Atlas 2011 edition. Three-letter codes are ISO standard codes for country names.
Figure 1 Relationship between obesity and diabetes prevalence rates worldwide. Obesity prevalence is defined as the percentage of the population aged 15 to 100 years old with body mass index greater than or equal to 30 kg/meters squared, from the World Health Organization Global Infobase 2012 edition. Diabetes prevalence is defined as the percentage of the population aged 20 to 79 years old with diabetes, from the International Diabetes Federation Diabetes Atlas 2011 edition. Three-letter codes are ISO standard codes for country names.CC BY · PubMed Central
Figure 2 Adjusted association of sugar availability (kcal/person/day) with diabetes prevalence (% adults 20–79 years old). Regression line is adjusted for all control variables listed in Table 1, including time-trends (period-effects).
Figure 2 Adjusted association of sugar availability (kcal/person/day) with diabetes prevalence (% adults 20–79 years old). Regression line is adjusted for all control variables listed in Table 1, including time-trends (period-effects).CC BY · PubMed Central

Verification

Claims the paper makes

28 Own result · 15 Not checked yet · 12 Own interpretation · 11 Own method · 4 No basis given · 1 Partly supported · accuracy not yet measured

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Show all 32 claims

  • It may state two separate claims as one. 32
  • The quote only partly states this claim. 1
  • Probably not a substantial claim. 11
39 of 39
  • The paper relies on this without support.

    Food supply data on market availability accurately reflect population-level sugar intake or consumption.

    “We used United Nations Food and Agricultural Organization food supply data [26] to capture market availability of different food items (sugars, fibers, fruits, meats, cereals, oils, and total food) in kilocalories per person per day in each country for each year of the analysis.”
  • The paper relies on this without support.

    International Diabetes Federation diabetes prevalence estimates are valid and comparable across countries and years.

    “The dependent variables in the analysis were International Diabetes Federation estimates of diabetes prevalence among persons aged 20 to 79 years old from 2000 through 2010 [6].”
  • The paper relies on this without support.

    No direct measures of actual human consumption that account for food wastage and provide precise measures of food consumption internationally exist.

    “as there are no direct measures of actual human consumption that can account for food wastage and provide precise measures of food consumption internationally.”
3 of 3

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Citations

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Metadata

Authors
Basu, S., Yoffe, P., Hills, N., & Lustig, R. H.
Affiliations
  • Stanford University (US)
  • University of California, Berkeley (US)
  • University of California, San Francisco (US)
Corresponding author
Basu, Sanjay
Venue
PLoS ONE
Published
2013-02-27
Volume
8
Issue
2
Pages
e57873
ISSN
1932-6203 (ISSN-L)
OpenAlex
W2014750665
Cited by
435
References
43
Citations by year
2026: 11 · 2025: 10 · 2024: 16 · 2023: 21 · 2022: 29 · 2021: 66 · 2020: 37 · 2019: 31 · 2018: 34 · 2017: 34 · 2016: 48 · 2015: 41 · 2014: 31 · 2013: 23
FWCI
37.57
Type
journal article
Language
en
Open access
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • RePEc: Research Papers in Economics (submittedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • eScholarship (California Digital Library) (submittedVersion)
  • Figshare (submittedVersion, cc-by)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diet, Metabolism, and Disease
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Obesity, Physical Activity, Diet
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes, Cardiovascular Risks, and Lipoproteins
Keywords
sugar consumption, type 2 diabetes, diabetes prevalence, sugar availability, soft drink consumption, obesity, dietary exposure, dose-response relationship, cross-national comparison, socioeconomic determinants of health, urbanization, income
MeSH terms
Adult, Aged, Energy Intake, Carbohydrates, Cross-Sectional Studies, Diabetes Mellitus, Type 2, Humans, Middle Aged, Obesity, Selection Bias, Prevalence, Models, Econometric, Young Adult

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