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There is
increasing evidence to show that consuming sugar-sweetened beverages (SSBs) is
associated with increased risk of obesity or elevated body mass index (BMI) and
type 2 diabetes mellitus (T2DM). Conversely, several empirical studies have
also shown that reduced consumption of SSBs reduces the risk of obesity and
developing T2DM.1-10Obesity
is a global public health problem of pandemic proportions .2 An estimated 1.6 billion adults worldwide were overweight
with BMI of 25kg/m2 and over and approximately 400 million of these
adult were obese with BMI of 30kg/m2 and greater in 2005. It was
estimated that these numbers will reach 2.3 billion for overweight and 700
million for obese adults in 2015.2 In the United
States, there was an increase in the percentage of overweight adults from 47%
to 69% and in the percentage of obese adults from 15% to 36% within a forty
year period from the late 1970s to 2010 .11 This increase is
of particular concern in children and adolescents, in whom the obesity
prevalence has more than doubled to 16.9% over the last thirty years since the
1970s.12 In 2008, the
healthcare expenditure attributed to obesity in the United States was
approximated to be $147 per annum .13

Associated with rising prevalence of obesity worldwide is
the prevalence of T2DM. According to a 2012 International Diabetes Federation
(IDF) estimate, more than 366 million people suffer with T2DM, a number
projected to reach 552 million worldwide by 2030. 14 Specifically, the
prevalence of T2DM in the United States, according to a 2010 Centers for
Disease Control report has nearly doubled from about 5.3% between 1976 and 1980
to about 11.3% (CDC, 2010).

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Body Mass Index
(BMI) is a measure of body fat content used to characterize obesity in men and
BMI can be used as a proxy for the risk of developing type 2 diabetes mellitus
(T2DM) in men and women.18-23
BMI has been shown to be strongly correlated with percentage of body fat and is
commonly used to predict incident cases of T2DM in both women and men when
compared to other  anthropometric
measurements of body fat content such as body adiposity index, waist
circumference, hip circumference, skinfold thickness, and bioelectric impedance
analysis .18,19

Review of the Literature

Park and colleagues (2016) reported a
steady to high frequency in SSBs consumption,  in 23 out of the 50 in the United States, using
2013 BRFSS data.24 In a
cross-sectional study of four cycles (2003-2010) of the National Health and Nutrition Examination Survey (NHANES) in 2014, Drewnowski and Rehm
reported that SSBs are the largest source of added sugars to the diet of
children and adolescents in the United States.25 In a systematic
review, meta-analysis and estimation of population fraction by Imamura et al.
in 2016, 54.4% of the United States population still consumed SSBs with an
estimated consumption of 284(SD 412) gallons per day.

Sugar Sweetened Beverage Consumption,
Obesity and Type 2 Diabetes

 In a meta-analysis and systematic review of dose-response of association
between sugar-sweetened and artificially sweetened soft drinks and type 2
diabetes, Greenwood et al.,26 found
a positive association  between
sugar-sweetened soft drink intake and type 2 diabetes risk, although the
association was weakened when adjustments were made for BMI. The weak
association between SSBs and T2D when adjusting for BMI showed that BMI is involved
in the causal pathway.26 In a
related systematic review by Imamura et al.,27 the authors have
empirical evidence to show that controlling for adiposity, the habitual
consumption of sugar sweetened beverages, artificially sweetened beverages, and
fruit juice was prospectively associated with incident type 2 diabetes. Results
from Imamura and colleagues’ prospective analysis provided an efficacy estimate
which projects that over a period of 10 years an estimated 2 million new cases
of T2D will be attributed to SSBs consumption.27

Empirical evidence till date shows that there
is an association between SSBs consumption and increased BMI, evidence from the
review of literature on SSBs consumption as a risk factor for weight gain and
obesity by Bes-Rastrollo and colleagues in 2016 suggests that added sugars,
especially SSB consumption, are an important risk factor for weight gain and

Although the biological mechanism of the
association between SSBs and obesity is not clearly defined, Qi and colleagues suggests
that the intake of SSBs contributes to obesity through the following potential
mechanisms; due to the high caloric content and low satiety of SSBs, it does
not fully compensate for these liquid calories, resulting in an increased total
energy intake. Secondly, because of the large amounts of rapidly absorbable
carbohydrates in sugar-sweetened beverages, greater consumption may increase
the risks of insulin resistance, beta-cell dysfunction, inflammation, visceral
adiposity, and other metabolic disorders.29,30 

Many studies have been able to show that SSBs
consumption increases the risk of elevated BMI, however, there is currently a
paucity of research on the association of SSBs consumption and BMI increase in
United States’ adult population. Our study purpose is to understand the
association of SSBs consumption and BMI among United States adults in order to
make a case for the reduction of consumption of SSBs targeted ultimately at
reducing the incidence of T2DM.


Sample and survey administration

We used
2016 Behavioral Risk Factor Surveillance System (BRFSS) data for which the

response rate was 47%.31 BRFSS
data is a nationally representative data that collects information about U.S.
residents regarding their health-related risk behaviors, chronic health
conditions, and use of preventive services.  It is a state-based, random- digit-dialed
telephone survey conducted annually by the Centers for Disease Control and
Prevention (CDC) and state health departments. Every year, several optional
modules are offered on the BRFSS questionnaires. In 2013, an optional module on
SSB intake was introduced for use in 23 states and the District of Columbia.
The CDC Human Research Protection Office determined BRFSS to be exempt


Daily SSB intake was determined by two survey
questions: “During the past 30 days, how often did you drink regular soda or
pop that contains sugar”?31 Do not
include diet soda or diet pop and “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.31 For
each question, respondents reported the number of times per day, per week, or
per month they consumed these beverages.31 We
converted weekly or monthly intake to daily intake and calculated SSB intake
frequency by combining consumption frequency from both questions. We created two
mutually exclusive SSB categories of consumption frequency (>0 to 1 and ?2

Body Mass Index (BMI) (kg/m2) calculated from
self-reported weight and height data, weight status was classified as
underweight (BMI < 18.5), normal weight (BMI 18.5–<25), over-weight (BMI 25–<30), and obese (BMI ? 30). Covariates were age group (18–29, 30–39, 40–49, 50–59, 60–69, or ?70 years); sex; race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, and non-Hispanic other); and education (

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