NEJM Focuses on Studies Examining Effects of Sugar-Sweetened Beverages

The New England Journal of Medicine (NEJM) has published a series of studies and commentary on the purported health effects of consuming sugar-sweetened beverages. The American Beverage Association issued a statement contending that studies focusing “solely on sugar-sweetened beverages” as an alleged cause of obesity “or any single source of calories, do nothing meaningful to help address this serious issue. The fact remains: sugar-sweetened beverages are not driving obesity. By every measure, sugar-sweetened beverages play a small and declining role in the American diet.”

The studies included Janne de Ruyter, et al., “A Trial of Sugar-free or Sugar-Sweetened Beverages and Body Weight in Children,” (concluding, “[m]asked replacement of sugar-containing beverages with noncaloric beverages reduced weight gain and fat accumulation in normal-weight children.”); Cara Ebbeling, et al., “A Randomized Trial of Sugar-Sweetened Beverages and Adolescent Body Weight,” (concluding, “[a]mong overweight and obese adolescents, the increase in [body mass index] was smaller in the experimental group [which decreased sugar-sweetened beverage consumption] than in the control group after a 1-year intervention . . . but not at the 2-year follow up.”); and Qibin Qi, et al., “Sugar-Sweetened Beverages and Genetic Risk of Obesity (concluding, “[t]he genetic association of adiposity appeared to be more pronounced with greater intake of sugar-sweetened beverages.”).”

In an editorial titled “Calories from Soft-Drinks—Do They Matter?,” Sonia Caprio, with the Yale School of Medicine, Department of Pediatrics, contends that these three studies “provide new data showing that consumption of sugar-sweetened beverages may influence the development of obesity among children, adolescents, and adults.” She notes that Qi’s study “provides strong evidence that there is a significant interaction between an important dietary factor—intake of sugar-sweetened beverages—and a genetic predisposition score, obesity, and the risk of obesity. Hence, participants with a greater genetic predisposition may be more susceptible to the adverse effects of sugar-sweetened beverages on obesity; this is a clear example of gene-environment interaction.” While Caprio acknowledges that mechanisms accounting for the “observed interaction” are not provided by the study, she contends that it “provides support for the need to test whether interventions aimed at reducing the intake of sugary drinks to reduce the risk of obesity might be more effective in persons with a high genetic-predisposition score.”

Caprio characterizes the two other studies as rigorously designed randomized, controlled trials, and concludes that all three studies “suggest that calories form sugar-sweetened beverages do matter.” She calls for policy decisions to address factors in addition to the consumption of sugar-sweetened beverages, including increasing physical activity “to stem the obesity epidemic and its effects.”

New York City Health Commissioner Thomas Farley and Cornell University Marketing Professor Brian Wansink, whose comments about government’s obligation to address the obesity epidemic were summarized in Issue 454 of this Update, provide further point-counterpoint commentary in this special NEJM issue. Farley supports the regulation of sugar-sweetened beverages, stating “If a harmful chemical in schools were causing our children to get sick, people would demand government regulation to protect them. It is therefore difficult to argue against a government response to an epidemic of obesity that kills more than 100,000 persons a year in the United States and has an environmental origin.”

Wansink cites Prohibition as an example of government action to “wipe out the ills of alcohol” that “could not withstand the violent backlash, subversion, and illegal consequences that quickly followed.” He argues that (i) “consumption of other choices will not remain constant when we tinker with what is available to eat or drink,” (ii) “a preference for less healthful foods, including sugar-sweetened beverages, strengthens when it appears that a tax is being used to restrict consumption,” and (iii) “there is a way forward that has fewer risks and that can place children squarely in our corner. The use of simple behavioral nudges, such as making soft drinks less visible and less convenient, can have a big effect on consumption, while still allowing the children’s (or their parents’) own choice.” According to Wansink, “voluntary approaches are much more likely than regulations to create long-term behavioral habits and much less likely to create a class of soft-drink freedom fighters.”

In a related development, the American Public Health Association will be holding its 140th Annual Meeting & Expo, October 27-31, 2012, in San Francisco and has scheduled a number of sessions addressing food marketing to children, policy options for regulators, legislation seeking to limit obesity-related litigation, sodium content, and front-of-package labeling, among
other matters.

October 29 sessions include:

• Michele Simon, “Food stamps, follow the money: Are corporations
  profiting from hungry Americans?”
• Sarah Mart, “Public health and alcohol: Corporate influence on regulation”
• Ruth Malone, “Public health: Becoming a tobacco industry competitor”
• Juliet Sims, et al., “We’re not buying it: An advocacy approach to exposing
  food marketing to children”
• Elizabeth Taylor Quilliam, et al., “Integrated tactics for marketing food to
  children: Below the belt and regulation radar”
• Lisa Powell, et al., “Nutritional content of food advertising directed to
  children on television”
• Kelly Brownell, “The food marketing environment: Barriers and opportunities
  to action to improve children’s health”
• Kelly Brownell, et al., “What are they thinking? Parents’ attitudes about
  food marketing to their children”
• Jennifer Pomeranz, “Policy options to regulate food marketing at
  the local level”
• Samantha Graff, “Policy strategies for improving the nutritional profile of
  fast food purchases”

October 30 sessions include:

• Michele Simon and Ryan Treffers, “Control state politics: Is Costco victory
  in Washington a wake-up call for public health?”
• Tara Ramanathan, “Assessing the use of law on reducing sodium in the
  food supply”

October 31 sessions include:

• Lainie Rutkow and Jennifer Pomeranz, “Front-of-package labeling, food
  advertising, and the legal environment”
• Cara Wilking, “Cheeseburger bills: State laws to limit future obesity-related
  public health litigation.”