Diabetes mellitus is a major cause of illness and premature death in most countries.¹ Efforts to reduce the impact of diabetes complications have been predominantly aimed at controlling hyperglycemia, hypertension, and dyslipidemia by using medication strategies, despite the lack of evidence of long-term benefits.^2,3 However, diabetes management should extend to an overall intervention strategy that includes lifestyle modification to reduce the risk of complications.⁴

Public health policies, including in Europe, are considering measures and recommendations to limit the intake of added or free sugars. For such policies to be efficient and monitored, a precise knowledge of the current situation regarding sugar intake in Europe is needed. This review summarizes published or re-analyzed data from 11 representative surveys in Belgium, France, Denmark, Hungary, Ireland, Italy, Norway, The Netherlands, Spain and the UK. Relative intakes were higher in children than in adults: total sugars ranged between 15 and 21% of energy intake in adults and between 16 and 26% in children. Added sugars (or non-milk extrinsic sugars (NMES), in the UK) contributed 7 to 11% of total energy intake in adults and represented a higher proportion of children’s energy intake (11 to 17%). Educational level did not significantly affect intakes of total or added sugars in France and the Netherlands. Sweet products (e.g. confectionery, chocolates, cakes and biscuits, sugar, and jam) were major contributors to total sugars intake in all countries, genders and age groups, followed by fruits, beverages and dairy products. Fruits contributed more and beverages contributed less to adults’ total sugars intakes than to children’s. Added sugars were provided mostly by sweet products (36 to 61% in adults and 40 to 50% in children), followed by beverages (12 to 31% in adults and 20 to 34% in children, fruit juices excluded), then by dairy products (4 to 15% in adults and 6 to 18% in children). Caution is needed, however, as survey methodologies differ on important items such as dietary data collection, food composition tables or estimation of added sugars. Cross-country comparisons are thus not meaningful and overall information might thus not be robust enough to provide a solid basis for implementation of policy measures. Data nevertheless confirm that intakes of total and added sugars are high in the European countries considered, especially in children, and point to sweet products and beverages as the major contributors to added sugar intakes.

Several prospective studies have reported that risk of type 2 diabetes (T2DM) is elevated in meat consumers, especially when processed meats are consumed. Elevated risks of coronary heart disease (CHD) and stroke in meat consumers have also been reported. In this overview, the evidence regarding meat consumption and the risk of diabetes, both type 1 diabetes (T1DM) and T2DM and their macro- and microvascular complications, is reviewed. For T2DM, we performed a new meta-analysis including publications up to October 2012. For T1DM, only a few studies have reported increased risks for meat consumers or for high intake of saturated fatty acids and nitrates and nitrites. For T2DM, CHD, and stroke, the evidence is strongest. Per 100 g of total meat, the pooled relative risk (RR) for T2DM is 1.15 (95 % CI 1.07–1.24), for (unprocessed) red meat 1.13 (95 % CI 1.03–1.23), and for poultry 1.04 (95 % CI 0.99–1.33); per 50 g of processed meat, the pooled RR is 1.32 (95 % CI 1.19–1.48). Hence, the strongest association regarding T2DM is observed for processed (red) meat. A similar observation has been made for CHD. For stroke, however, a recent meta-analysis shows moderately elevated risks for meat consumers, for processed as well as for fresh meats. For the microvascular complications of diabetes, few prospective data were available, but suggestions for elevated risks can be derived from findings on hyperglycemia and hypertension. The results are discussed in the light of the typical nutrients and other compounds present in meat—that is, saturated and trans fatty acids, dietary cholesterol, protein and amino acids, heme-iron, sodium, nitrites and nitrosamines, and advanced glycation end products. In light of these findings, a diet moderate to low in red meat, unprocessed and lean, and prepared at moderate temperatures is probably the best choice from the public health point of view.

Dietary fiber, carbohydrate quality and quantity are associated with mortality risk in the general population. Whether this is also the case among diabetes patients is unknown. To assess the associations of dietary fiber, glycemic load, glycemic index, carbohydrate, sugar, and starch intake with mortality risk in individuals with diabetes. This study was a prospective cohort study among 6,192 individuals with confirmed diabetes mellitus (mean age of 57.4 years, and median diabetes duration of 4.4 years at baseline) from the European Prospective Investigation into Cancer and Nutrition (EPIC). Dietary intake was assessed at baseline (1992–2000) with validated dietary questionnaires. Cox proportional hazards analysis was performed to estimate hazard ratios (HRs) for all-cause and cardiovascular mortality, while adjusting for CVD-related, diabetes-related, and nutritional factors. During a median follow-up of 9.2 y, 791 deaths were recorded, 306 due to CVD. Dietary fiber was inversely associated with all-cause mortality risk (adjusted HR per SD increase, 0.83 [95% CI, 0.75–0.91]) and CVD mortality risk (0.76[0.64–0.89]). No significant associations were observed for glycemic load, glycemic index, carbohydrate, sugar, or starch. Glycemic load (1.42[1.07–1.88]), carbohydrate (1.67[1.18–2.37]) and sugar intake (1.53[1.12–2.09]) were associated with an increased total mortality risk among normal weight individuals (BMI≤25 kg/m²; 22% of study population) but not among overweight individuals (P interaction≤0.04). These associations became stronger after exclusion of energy misreporters. High fiber intake was associated with a decreased mortality risk. High glycemic load, carbohydrate and sugar intake were associated with an increased mortality risk in normal weight individuals with diabetes.

There has been long-standing debate about whether diabetes is a causal risk factor for pancreatic cancer or a consequence of tumour development. Prospective epidemiological studies have shown variable relationships between pancreatic cancer risk and blood markers of glucose and insulin metabolism, overall and as a function of lag times between marker measurements (blood donation) and date of tumour diagnosis.

Individuals with diabetes mellitus are advised to achieve a healthy weight to prevent complications. However, fat mass distribution has hardly been investigated as a risk factor for diabetes complications. The authors studied associations between body mass index, waist circumference, waist/hip ratio, and waist/height ratio and mortality among individuals with diabetes mellitus. Within the European Prospective Investigation into Cancer and Nutrition, a subcohort was defined as 5,435 individuals with a confirmed self-report of diabetes mellitus at baseline in 1992–2000. Participants were aged 57.3 (standard deviation, 6.3) years, 54% were men, the median diabetes duration was 4.6 (interquartile range, 2.0–9.8) years, and 22% of the participants used insulin. Body mass index, as indicator of general obesity, was not associated with higher mortality, whereas all measurements of abdominal obesity showed a positive association. Associations generally were slightly weaker in women. The strongest association was observed for waist/height ratio: In the fifth quintile, the hazard rate ratio was 1.88 (95% confidence interval: 1.33, 2.65) for men and 2.46 (95% confidence interval: 1.46, 4.14) for women. Measurements of abdominal, but not general, adiposity were associated with higher mortality in diabetic individuals. The waist/height ratio showed the strongest association. Respective indicators might be investigated in risk prediction models.