Soft Drinks─ a Hidden Driver of the Obesity Epidemic

• Most soft drinks are sugar-sweetened beverages (SSBs), except for those specifically marketed as diet drinks, and have been associated with obesity, metabolic syndrome, diabetes, elevated uric acid, and gout.¹ All of these have been implicated in cardiovascular risk.

• Hundred percent fruit juice that is not blended with added sweeteners is not considered SSB. People who consume 1-2 soft drinks/day had a 26% greater risk of developing diabetes and 20% risk of developing metabolic syndrome.^1-3

• Consumption of soft drinks has increased across the globe and account for 8% of caloric intake in the US. Soft drinks are the primary sources of added sugars in American diets, including that of children and adolescents.^{4, 5}

• Over the past 35 years, the total caloric intake in the US increased by an average 300 calories and soft drinks accounts for half it.⁶  During the same period, the serving size of soft drinks has also increased from 6oz (70 calories) to 12oz (140 calories).^{5, 7}  This has resulted in a doubling of the per capita consumption of calories from soft drinks contributing to the epidemic of obesity since there was no concomitant increase in physical activity.⁸ A similar phenomenon is occurring throughout the world.

• The principal ingredient in soft drinks is high fructose corn syrup (HFCS) which is a mixture of free fructose 55% and glucose 45% whereas sucrose is a disaccharide with 50% glucose and 50% fructose. HFCS now represents >40% of caloric sweeteners added to foods and beverages and is the sole caloric sweetener in soft drinks in the US.

• In sharp contrast to HFCS, fruits such as; grapes, apple, persimmons, and blueberries contain 5-10% fructose. In fruits, fructose serves as a marker of foods that are nutritiously rich.

• The increased use of HFCS in the US mirrors the rapid increase in obesity with an average consumption of 200 calories/day among Americans. Current American consumption of sugar and HFCS combined is approximately 150 lb per year or 500 calories per day.

• Despite the first-ever per-capita declines in soft drink sales, 4 companies still sold more than 14 billion gallons of calorie-laden soft drinks in 2008. That is equivalent to about 506 12-oz. servings per year, or 17-oz. per day, for every man, woman, and child in the US.

• HFCS does not suppress circulating ghrelin, the major appetite suppressant hormone. As a result, calorically sweetened beverages may enhance caloric overconsumption.⁹ The weight of epidemiologic and experimental evidence indicates that a greater consumption of soft drinks is associated with weight gain and obesity─ the principal driver of diabetes.

• Due to their high amounts of rapidly absorbable carbohydrates and the large quantities consumed, soft drinks may increase diabetes and cardiovascular risk independently of obesity through high dietary glycemic load leading to inflammation, insulin resistance, and impaired β-cell function.¹⁰

• Soft drinks contribute up to 10%-15% of total daily energy intake among children.⁴ A meta-analysis of all the studies to date has shown a strong positive correlation between soft drink consumption and weight gain in the pediatric population.¹¹

• During regular soft drink consumption, fat accumulates in the liver by the primary effect of fructose which increases lipogenesis.³

• Obesity costs around $95 billion in healthcare expenditure each year in the US, and much of that cost is carried by the federal and state governments. Since, excessive consumption of soft drinks is one of the largest drivers of the current obesity epidemic in children and adults, soft drinks are a special target of many obesity-prevention strategies.^{12, 13}  Some have proposed vending machine restrictions and taxing soft drinks to curb the consumption of soft drinks.¹⁴

• Taxing soft drinks can reduce the obesity burden in the US as well as create extra revenue for public health initiatives, according to the Center for Science in the Public Interest (CSPI). A federal excise tax of $0.01 per 12-oz serving would raise around $1.5 billion a year and $11 billion if the excise tax is increased to $0.08.

• Such a tax would decrease consumption and increase funding for health promotion programs. Although a soft drink tax is already levied in several cities and states, the tax amount is small and little goes to health promotion programs

• Soft drinks include regular (non-diet) carbonated sodas, energy drinks, sports drinks, fruit drinks, ready-to-drink teas, vitamin waters, and iced tea drinks.¹

• Sufficient evidence exists for public health strategies to discourage consumption of sugary soft drinks as part of a healthy lifestyle.¹⁵ An expert panel recommends that the consumption of beverages with no or few calories should take precedence over the consumption of beverages that contain calories.¹⁶

• Those who drink soft drinks should limit the quantity to 36 ounces per week (5oz/d).¹⁰  Better yet, soft drinks should be replaced with healthy alternatives like water.

Sources

1. Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, Hu FB. Sugar-sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. Nov 2010;33(11):2477-2483.

2. Hostmark AT. The Oslo Health Study: a Dietary Index estimating high intake of soft drinks and low intake of fruits and vegetables was positively associated with components of the metabolic syndrome. Appl Physiol Nutr Metab. Dec 2010;35(6):816-825.

3. Nseir W, Nassar F, Assy N. Soft drinks consumption and nonalcoholic fatty liver disease. World J Gastroenterol. Jun 7 2010;16(21):2579-2588.

4. Wang Y.C, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics. Jun 2008;121(6):e1604-1614.

5. Briefel R R, Johnson CL. Secular trends in dietary intake in the United States. Annu Rev Nutr. 2004;24:401-431.

6. Nielsen SJ, Siega-Riz AM, Popkin BM. Trends in energy intake in U.S. between 1977 and 1996: similar shifts seen across age groups. Obesity research. May 2002;10(5):370-378.

7. Mensink RP, Zock PL, Kester AD, Katan MB. Effects of dietary fatty acids and carbohydrates on the ratio of serum total to HDL cholesterol and on serum lipids and apolipoproteins: a meta-analysis of 60 controlled trials. Am J Clin Nutr. May 2003;77(5):1146-1155.

8. Ogden C L, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999-2004. Jama. Apr 5 2006;295(13):1549-1555.

9. Bray GA, Nielsen SJ, Popkin BM. Consumption of high-fructose corn syrup in beverages may play a role in the epidemic of obesity. Am J Clin Nutr. Apr 2004;79(4):537-543.

10. Johnson RK, Appel LJ, Brands M, et al. Dietary Sugars Intake and Cardiovascular Health. A Scientific Statement From the American Heart Association. Circulation. Aug 24 2009.

11. Forshee RA, Anderson PA, Storey ML. Sugar-sweetened beverages and body mass index in children and adolescents: a meta-analysis. Am J Clin Nutr. Jun 2008;87(6):1662-1671.

12. James J, Kerr D. Prevention of childhood obesity by reducing soft drinks. Int J Obes (Lond). Sep 2005;29 Suppl 2:S54-57.

13. Jimenez-Cruz A, Bacardi-Gascon M, Jones EG. Consumption of fruits, vegetables, soft drinks, and high-fat-containing snacks among Mexican children on the Mexico-U.S. border. Arch Med Res. Jan-Feb 2002;33(1):74-80.

14. Fletcher JM, Frisvold D, Tefft N. Taxing soft drinks and restricting access to vending machines to curb child obesity. Health Aff (Millwood). May 2010;29(5):1059-1066.

15. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. Aug 2006;84(2):274-288.

16. Popkin BM, Armstrong LE, Bray GM, Caballero B, Frei B, Willett WC. A new proposed guidance system for beverage consumption in the United States. Am J Clin Nutr. Mar 2006;83(3):529-542.

17. Arria AM. The “high” risk of energy drinks. JAMA. Feb 9 2011;305(6):600-601.