What is the question?

• The question is: What is the relationship between low- and no-calorie sweetened beverage consumption and risk of type 2 diabetes? The populations of interest for this question include infants, children, adolescents, adults, and older adults.

Why was this question asked?

• This systematic review was conducted by the 2025 Dietary Guidelines Advisory Committee as part of the process to develop the Dietary Guidelines for Americans, 2025-2030.

How was this question answered?

• The Committee conducted a new systematic review to answer this question with support from the USDA Nutrition Evidence Systematic Review team.

What is the answer to the question?

• A conclusion statement cannot be drawn about the relationship between low- and no-calorie sweetened beverage consumption by infants, children, and adolescents and risk of type 2 diabetes because there is not enough evidence available.
• Low- and no-calorie sweetened beverage consumption by adults and older adults may not be associated with risk of type 2 diabetes. This conclusion statement is based on evidence graded as limited.

How up-to-date is this systematic review?

• Conclusion statements from this review are based on articles published between January 2000 and January 2024.

Background

• This systematic review was conducted by the 2025 Dietary Guidelines Advisory Committee as part of the process to develop the Dietary Guidelines for Americans, 2025-2030. The U.S. Departments of Health and Human Services (HHS) and Agriculture (USDA) appointed the 2025 Dietary Guidelines Advisory Committee (Committee) in January 2023 to review evidence on high priority scientific questions related to diet and health. Their review forms the basis of their independent, science-based advice and recommendations to HHS and USDA, which is considered as the Departments develop the next edition of the Dietary Guidelines. As part of that process, the Committee conducted a systematic review with support from USDA’s Nutrition Evidence Systematic Review (NESR) team to answer the following question: What is the relationship between low- and no-calorie sweetened beverage consumption and risk of type 2 diabetes?

Methods

• The Committee conducted a systematic review using the methodology of the USDA NESR team. The Committee first developed a protocol. The intervention/exposure was low- and no-calorie sweetened beverage consumption   in infants, children, adolescents, adults, and older adults, the comparators were consumption of a different amount of low- and no-calorie sweetened beverages (including no consumption and versions diluted with water) or water and the outcomes were fasting blood glucose, fasting insulin, glucose tolerance/insulin resistance, hemoglobin A1c, prediabetes, and risk of type 2 diabetes in infants, children, adolescents, adults, and older adults. Additional inclusion criteria were established for the following study characteristics: a) use randomized or non-randomized controlled trial, prospective or retrospective cohort, nested case-control, or Mendelian randomization study designs, b) be published in English in peer-reviewed journals, c) be from countries classified as high or very high on the Human Development Index, and d) enroll participants with a range of health statuses. The review excluded intervention studies less than 12-week duration for hemoglobin A1C, prediabetes, and type 2 diabetes, and intervention studies less than 4-week study duration for fasting blood glucose, fasting insulin, and glucose tolerance/insulin resistance.
• NESR librarians conducted a literature search in PubMed, Embase, CINAHL, and Cochrane to identify articles published between January 2000 and January 2024. Two NESR analysts independently screened all electronic results and the reference lists of included articles based on the pre-determined criteria.
• NESR analysts extracted data, from each included article, with a second analyst verifying accuracy of the extraction. Two NESR analysts independently conducted a formal risk of bias assessment, by study design, for each included article, then reconciled any differences in the assessment. The Committee qualitatively synthesized the evidence, with attention given to the overarching themes or key concepts from the findings, similarities and differences between studies, and factors that may have affected the results. The Committee developed conclusion statements and graded the strength of evidence based on its consistency, precision, risk of bias, directness and generalizability.

Results

Infants, children, and adolescents

Conclusion statement and grade

• A conclusion statement cannot be drawn about the relationship between low- and no-calorie sweetened beverage consumption by infants, children, and adolescents and risk of type 2 diabetes because there is not enough evidence available. (Grade: Grade Not Assignable)

Summary of the evidence

• One prospective cohort study met the inclusion criteria for this review in infants, children, and adolescents.
• The Committee was not able to draw a conclusion because there was not enough evidence available.

Adults and older adults

Conclusion statement and grade

• Low- and no-calorie sweetened beverage consumption by adults and older adults may not be associated with risk of type 2 diabetes. This conclusion statement is based on evidence graded as limited. (Grade: Limited)

Summary of the evidence

• Thirty-two articles met the inclusion criteria for this review in adults and older adults. Eleven were randomized controlled trials, 1 was a nested case control study, and 21 were prospective cohort studies.
• The direction of results and size of effects were too different across studies.
• The size of study groups was small is some studies.
• Some studies were designed and conducted well.
• The populations, interventions/exposures, and comparators that were examined directly represent those of interest in this review, but the outcomes do not.
• The evidence applies to the U.S. population but may not apply to diverse subgroups based on socioeconomic position and race and/or ethnicity.

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Suggested citation: Giovannucci E, Taylor CA, Deierlein AL, Raynor HA, Hoelscher DM, Anderson CAM, Booth SL, Fung TT, Gardner CD, Stanford FC, Talegawkar SA, Tobias DK, Cole NC, Kingshipp BJ, Webster A, Higgins M, Butera G, Terry N, Obbagy J. Low- and No-Calorie Sweetened Beverages and Risk of Type 2 Diabetes: A Systematic Review. November 2024. U.S. Department of Agriculture, Food and Nutrition Service, Center for Nutrition Policy and Promotion, Nutrition Evidence Systematic Review. Available at: https://doi.org/10.52570/NESR.DGAC2025.SR15