In my first post about sugar I discussed increased cardiovascular risk associated with consumption of added sugar, sweetened foods and beverages. This post will discuss other risks including childhood obesity and adult obesity, diabetes and Metabolic syndrome.

The marketing efforts directed at young children by soda producers and fast food restaurants is astounding. You can view a video produced by a concerned mother here.

Some highlights of the video include:

• 1:14 How her daughter’s obsession with one particular person made her realize what was happening.
• 2:20 Can you guess how much money the food industry spends marketing to kids?
• 3:15 There’s even a term for the way they make children more annoying.
• 3:55 Find out just how many thousands of ads kids see if they watch a regular amount of television.
• 4:30 Here’s why just turning off the TV isn’t a solution.
• 4:50 Learn which school supplies are now sponsored by junk food.
• 5:54 Find out how companies like Coca-Cola and Pepsi are straight-up conning school communities to buy their products.
• 6:47 Here’s what she finds most upsetting.
• 8:10 And here’s how they get even more information about kids.
• 9:30 She talks about the life and death consequences that hang in the balance with this issue.
• 10:24 We’re seeing the most depressing innovations in health care now thanks to the food industry.
• 12:00 You’ll never believe where McDonald’s wanted to advertise.
• 13:01 Find out who’s fighting these food behemoths and saving generations to come.

You can read more about this topic here. Nutritional Content of Food and Beverage Products in Television Advertisements Seen on Children’s Programming.

So what’s all the fuss? Where is the data to support a connection between sweetened beverages, sweetened foods and obesity, diabetes and metabolic syndrome?

Let’s start with a study by Gitanjali Singh and associates from Harvard School of Public Health reported here, the Epidemiology and Prevention/Nutrition, Physical Activity and Metabolism 2013 Scientific Sessions. I read about this on Medscape published on-line. You must establish a user name and password to access these reviews, written for physicians and health professionals.

They reported that drinking large amounts of sugar sweetened beverages (SSBs) was associated with an increased body-mass index (BMI). Increased BMI is associated with deaths from diabetes, cardiovascular disease and cancer, so the authors calculated deaths associated with consumption SSBs from diabetes, CVD and cancer.

The researchers found that in 2010

“132,000 deaths from diabetes, 44,000 deaths from CVD, and 6000 deaths from cancer in the world could be attributed to drinking sugar-sweetened soft drinks, fruit juice, or sports beverages.”

“As part of the Global Burden of Disease study, the researchers obtained data from 114 national dietary surveys, representing more than 60% of the world’s population.

Based on data from large prospective cohort studies, they determined how changes in consumption of sugary drinks affected BMI, and next, how elevated BMI affected CVD, diabetes, and 7 obesity-related cancers (breast, uterine, esophageal, gallbladder, colorectal, kidney, and pancreatic cancer). Using data from the World Health Organization, they calculated the number of deaths from BMI-related CVD, diabetes, and cancer for men and for women aged 20 to 44, 45 to 64, and 65 years and older.”

Mexico had the highest number of deaths and Japan the lowest number of deaths attributed to the risk factor of sweetened beverage consumption. The USA had an estimated 25,000 deaths per year associated with drinking sugar sweetened beverages.

Medscape quoted Rachel K. Johnson, Ph.D. an AHA spokesperson.

“The evidence base that sugar-sweetened beverages are associated with excess weight gain is well established; what these investigators have done is to take it a step further by saying the excess weight gain that is attributable to sugary drinks actually increases the risk of death from diabetes, CVD, and cancer,” 

The obesity literature is in agreement that consuming beverages with calories does not result in a decrease in an equivalent amount of calories from solid food consumption. In fact studies of humans demonstrate that sugar sweetened beverages increase the total amount of calories consumed by an amount equal to the calories in the beverage. This is added calories that do not produce satiety. This is why my Manifesto recommends drinking only water, coffee, tea, and no sweetened beverages.

Here is a discussion about sugar added beverages vs sweetened solid foods.

Consumption of Added Sugars from Liquid but Not Solid Sources Predicts Impaired Glucose Homeostasis and Insulin Resistance among Youth at Risk of Obesity.

“a higher consumption (10 g/d) of added sugars from liquid sources was associated with 0.04 mmol/L higher fasting glucose, 2.3 pmol/L higher fasting insulin, 0.1 unit higher homeostasis model assessment of insulin resistance (HOMA-IR), and 0.4 unit lower Matsuda-insulin sensitivity index (Matsuda-ISI) in all participants (P < 0.01).”

Translation, just 10 grams (1/3 ounce) of added sugar from beverages increased fasting blood sugar, increased fasting insulin, worsened Insulin resistance. Insulin resistance is the precursor to diabetes. This is a chronic inflammatory state.

How much sugar is in a can of coke? Look here. How Much Sugar in Sodas and Beverages? 39 grams in a 12 oz bottle of coke, 79 grams in a 7-Eleven 32 oz Big gulp, 128 grams in a 7-Eleven 44 oz Super Gulp. 77 grams in a 20 oz bottle of Mountain Dew, But it only takes 10 grams a day to cause harm.

” liquid added sugars were a risk factor for the development of impaired glucose homeostasis and insulin resistance over 2 y among youth at risk of obesity.”

But let’s look at another study.

A meta-analysis published in 2010 reported that consumption of just one or two sugar-sweetened beverages per day is associated with a 26% greater risk of developing type 2 diabetes and a 20% increased risk of developing metabolic syndrome. Abstract

They concluded:

“In addition to weight gain, higher consumption of SSBs (sugar sweetened beverages) is associated with development of metabolic syndrome and type 2 diabetes. These data provide empirical evidence that intake of SSBs should be limited to reduce obesity-related risk of chronic metabolic diseases”

Malik VS, Popkin BM, Bray GA, et al. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: A meta-analysis. Diabetes Care 2010: 33:2477–2483.

At the time of this study publication,  cities and states were introducing legislation for “soda taxes” on sugar-sweetened beverages. There were also attempts to make sodas and sugar drinks ineligible for food stamp purchases. See the discussion here.

That same year the American Journal of Clinical Nutrition published a study Carbohydrate quantity and quality and risk of type 2 diabetes in the European Prospective Investigation into Cancer and Nutrition–Netherlands (EPIC-NL) study

We investigated the associations of dietary glycemic load (GL), glycemic index (GI), carbohydrate, and fiber intake with the incidence of type 2 diabetes.

They followed 37,846 participants for a mean follow up period of 10 years.

They concluded:

“Diets high in GL, GI, and starch and low in fiber were associated with an increased diabetes risk. Both carbohydrate quantity and quality seem to be important factors in diabetes prevention. “

There is plenty of low quality carbohydrate in the sodas featured above. And there is no fiber to slow the absorption of the sugar. You might as well start an IV and deliver 128 grams of super-gulp sugar directly into the blood.

In 2010 a Health Policy Report concerning the consumption of sweetened beverages was published in the New England Journal of Medicine.

The Public Health and Economic Benefits of Taxing Sugar-Sweetened Beverages – NEJMhpr0905723

They open up by stating:

Evidence that a tax on sugar sweetened beverages reduces the obesity rate: a meta-analysis.

This one concluded that:

Six articles from the USA showed that a higher price could also lead to a decrease in BMI, and decrease the prevalence of overweight and obesity.    

More studies from the search “sugar AND tax”.

Overall and income specific effect on prevalence of overweight and obesity of 20% sugar sweetened drink tax in UK: econometric and comparative risk assessment modelling study.

A substantial tax on sugar sweetened drinks could help reduce obesity.

Building a strategy for obesity prevention one piece at a time: the case of sugar-sweetened beverage taxation.

The potential impact on obesity of a 10% tax on sugar-sweetened beverages in Ireland, an effect assessment modelling study.

The sugar-sweetened beverage wars: public health and the role of the beverage industry.

A typology of beverage taxation: multiple approaches for obesity prevention and obesity prevention-related revenue generation.

Taxing sugar-sweetened beverages: the fight against obesity.

Sugar tax and obesity.

Intended and unintended consequences of a proposed national tax on sugar-sweetened beverages to combat the U.S. obesity problem.

Despite all of this discussion there has not been a “sugar tax” on sweetened beverages and here are several reasons.

Taxes on sugar-sweetened beverages: results from a 2011 national public opinion survey.

“Consumption of sugar-sweetened beverages including non-diet sodas, sport drinks, and energy drinks has been linked with obesity. Recent state and local efforts to tax these beverages have been unsuccessful. Enactment will be unlikely without public support, yet little research is available to assess how to effectively make the case for such taxes.

The objectives were to assess public opinion about arguments used commonly in tax debates regarding sugar-sweetened beverages and to assess differences in public opinion by respondents’ political party affiliation.

Findings indicated greater public agreement with anti- than pro-tax arguments. The most popular anti-tax argument was that a tax on sugar-sweetened beverages is arbitrary because it does not affect consumption of other unhealthy foods (60%). A majority also agreed that such taxes were a quick way for politicians to fill budget holes (58%); an unacceptable intrusion of government into people’s lives (53.8%); opposed by most Americans (53%); and harmful to the poor (51%). No pro-tax arguments were endorsed by a majority of the public. Respondents reported highest agreement with the argument that sugar-sweetened beverages were the single largest contributor to obesity (49%) and would raise revenue for obesity prevention (41%).”

So the relationship between sugar sweetened beverages and diabetes, obesity and metabolic syndrome seems well established but as a public policy issue there has been no traction on taxation remedies. And as the video above demonstrates, Coke and Pepsi have more than a foot in the door in our school systems and our homes (TV adds).

You can make a difference. vote here Tell the Soda Industry to Use Their Influence to Combat Childhood Obesity

A future post will discuss artificial sweeteners (diet beverages) which unfortunately also have a dismal track record.

Until next time,

Peace

Bob Hansen MD