Jacob Schor, ND, FABNO
April 3, 2019
Readers of this newsletter are probably not your typical American. Thus, this may be hard for you to believe. People living in the United States consume about 34 pounds (15.4 kilo) of sugar every year just from consuming sugary drinks. That’ not counting sugar in cakes, cookies, icecream, candy and a fair portion of other foods. This is from soft drinks and sweet beverages. Half of US adults and 2/3 of kids drink a sugary drink daily. By sugary drinks we mean soda and non-carbonated drinks as well.   Over the course of a year most people could half-fill a bathtub with the soda they drink. Again, for our regular readers this may be difficult to comprehend, but this is what the various websites claim.
Most of us assume that consuming this much sugar is unlikely to be a healthy practice. A recent study from researchers at Harvard’s T.H. Chan School of Public Health hints at just how dangerous our national soft drink habit may be to our health.
Vasanti Malik and colleagues analyzed data from two major long running cohorts, the Nurses’ Health Study and the Health Professional’s Follow-up study (HPFS) calculating both consumption of sugar sweetened beverages and comparing that with the risk of a participant in the study dying during a nearly three-decade period of time. The researchers analyzed data using Cox proportional hazards regression from 37,716 men in the HPFS and 80,647 women in the NHS seeking associations. Sugar sweetened beverages (SSBs) were just that, beverages with added sugars. Fruit juices were not included in the analysis. Total deaths, deaths from cardiovascular disease and death from cancer were compared with beverage consumption. Multiple covariates were tracked to eliminate possible confounders.
Drinking sugar sweetened beverages with any regularity increased a person’s risk of dying perhaps more than even we might have guessed. Women who consumed ≥2 servings of SSBs per day had a 63% higher risk of death. For men, risk of death increased by 29%. For men and women combined, HR was increased by 52%. These apparently high associations were weakened when all the covariate risks were factored into the equation. During 34 years of follow-up in the NHS, 23,432 deaths occurred, and during 28 years of follow-up in the HPFS, 13,004 deaths occurred.
Men and women with higher intakes of SSBs tended to be younger, less physically active, less likely to take a multivitamin, and more likely to smoke compared to those with lower intakes. SSB consumption was also associated with a higher intake of total energy, red and processed meat, and glycemic load. At the same time SSB consumption was associated with lower intake of whole grains and vegetables. All of these traits had to be factored in to the equations.
Intake of SSBs was associated with an increased risk for total mortality in both cohorts. Compared with those who consumed SSBs less than once per month, women who consumed ≥2 servings of SSBs per day had a 63% higher risk of death (HR, 1.63; 95% CI, 1.52, 1.75). For men there was a 29% increase in risk of death (HR, 1.29; 95% CI, 1.15, 1.44). The pooled HR (95% CI) was 1.52 (1.43, 1.61).
After adjusting for all the demographic and life- style factors (smoking, alcohol intake, postmenopausal hormone use [NHS], physical activity, family history of diabetes mellitus, family history of myocardial infarction, family history of cancer, multivitamin use, ethnicity, and aspirin use), the association was only a bit weakened; consumers still had a 30% higher risk (HR, 1.30; 95% CI, 1.22, 1.38). Additional adjustment for baseline hypertension and hypercholesterolemia, intakes of whole grains, fruit, vegetables, red and processed meat, total energy, and BMI further weakened the association further, dropping it to a 21% increase in risk (HR was 1.21 (95% CI, 1.13, 1.28; P trend, <0.001). But even with all the calculations, sugar sweetened drinks still accounted for a 21% increase in risk of dying.
Each serving per day increment in SSB was associated with a 7% higher risk of death (HR, 1.07; 95% CI, 1.05, 1.09). The association was stronger among those in the Nurses’ Health Study than HPFS (P interaction, 0.02). It didn’t seem to matter what type of SSB a person drank; the same 7% higher risk of death per daily serving held.
The risk for cardiovascular disease (CVD) mortality was even more pronounced than for cancer mortality.
In the pooled, fully adjusted analysis, compared to infrequent consumers, those who consumed ≥2 servings of SSBs per day had a 31% (HR, 1.31; 95% CI, 1.15, 1.50; P trend, <0.0001) higher risk of death from CVD. Estimates were greater in the NHS compared to HPFS but no interaction with sex was observed (P interaction, 0.70). Each serving per day increment of SSBs was associated with a 10% higher risk of CVD death (HR, 1.10; 95% CI, 1.06, 1.14).
Among women, there was a positive association between intake of SSB and 34% increased risk of breast cancer mortality (HR 1.34 [1.00, 1.80] 95% CI, P trend, 0.02;) comparing extreme categories.
Artificially sweetened beverages (ASB) appear to have a much smaller impact on health, or to be more accurate, death. ASB intake was positively associated with risk of total and CVD mortality in the highest category in the NHS: 2 or more servings per day was associated with a 10% increase in risk for total mortality and 15% for CVD mortality. Although risk trended steadily higher at lower consumption, the low consumption data did not reach statistical significance.
After adjusting for incidence of intermediate conditions (hypertension, hypercholesterolemia, type 2 diabetes mellitus, CHD, and stroke) during follow-up, the association between ASBs and total mortality in NHS was no longer significant (HR comparing extreme categories, 1.00; 95% CI, 0.94, 1.06; not shown). ASBS thus are not our worry, or at least shouldn’t be compared to the sugar sweetened beverages.
Intake of ASBs was not associated with cancer mortality in either cohort. At high intake levels, ≥4 servings/d in the NHS there was a positive association between ASB and total and CVD mortality. At ≥4 servings/d there was a 30% increase in risk for total mortality and a 43% increase for CVD mortality. Again, this was only seen in the NHS data; no associations were observed in HPFS. 
If our national agenda was simply to curb overpopulation, then we might argue for public policies that maintain our current sugar consumption patterns. But as we favor adoption of public policies that improve our population’s overall health and reduce morbidity and mortality, it would make better sense to try to curb the public’s current appetite for sugar sweetened beverages.
I should mention at some point that some of the biggest names at Harvard’s T.H. Chan’s School of Public Health are listed as authors of this recent study, including Eva Schernhammer and Willard Willet. When it comes to analyzing data obtained from these particular cohorts, these researchers are the international experts; they know what they are doing.
Let us just admit up front that consuming even what most would consider to be moderate amounts of sugar sweetened beverages (at 2 per day) may be associated with poor outcomes.
Current government dietary recommendations suggest added sugars should make up no more than 10% of total energy in the diet. Among young adults, SSBs alone contribute 9.3% of daily calories in men and 8.2% in women. Sweetened beverages by themselves nearly exceed the total suggested sugar daily intakes. Globally the situation may be worse than in the U.S..
The findings of this study are of particular timeliness. In April 2019, the American Academy of Pediatrics endorsed a number of policies to curb sugar consumption in children, including the still controversial policy of taxing sugar sweetened beverages. 
Berkeley, California was the first locality in the U.S. to implement a tax on SSBs, initiating the practice in January 2015.  Other cities have copied Berkeley’s example. It appears that imposing such taxes does have a significant impact at reducing sugar consumption. Researchers reported in the April 2019 issue of the American Journal of Public Health that there has been a significant 52% reduction in consumption of sugar sweetened soda in Berkeley following enactment of the law.
The National Bureau of Economic Research, a group supported by soda companies, reports that Philadelphia’s soda tax was associated with a reduction in “…. adults’ frequency of regular soda consumption by 10.4 times per month…”  On the other hand a close examination of sales records from stores suggests the response has been more complicated. A still unpublished study report that the group conducted suggests that although soda sales dropped within the city limits, it has increased outside the tax zones. People just started shopping for soda in the suburbs. Consumption may have only dropped by 20%.  Some readers might distrust their findings and remind me that I normally refrain from quoting unpublished ‘research’.
The soda industry is unsurprisingly unhappy with any moves to limit consumption of their products and are funding lobbying efforts to prevent enactment of these soda tax laws going forward. 
Four cities in California now have soda taxes. The beverage industry in California has been successful and halting any further local laws that may limit their sales. That have succeeded and gotten the legislature to pass a 12-year moratorium on further soda taxes. 
This is a clear example of big business trumping the interests of public health for their own profits.
Here in Colorado, Boulder passed a 2 cent per ounce tax in 2016. By August 2018, the City was on its way to taking in 5.8 million dollars. Boulder’s challenge has been what to do with the millions of dollars of extra income. The Colorado’s Taxpayers’ Bill of Rights (TABOR amendment to the State Constitution) requires the city to ask voters for their approval as whether that added revenue might be kept.
If there were ever a legislative issue that the naturopathic profession could and should get behind, it is this idea of a soda tax. We should actively support reduction of sugar sweetened beverage consumption. This study by Malik et al provides the most comprehensive data to date to quantify the risk to public health that consumption of these beverages creates.
Business interests that profit from maintaining these high levels of sugar consumption do not hesitate to advance various arguments against these ‘soda tax’ laws. Until such laws prove ineffective, we should err on the side of public health. Anything that helps reduce consumption of sugar sweetened beverages will likely improve public health. Let’s get behind passage of these laws. Statewide soda taxes were proposed this year in New York, Massachusetts, Rhode Island, Vermont and California. Arkansas was the last state to adopt a soft drink tax, passing it in 1992. Tennessee, Virginia and West Virginia have had sugar sweetened beverage taxes on the books for decades. 
Since 2007, a small but growing list of countries have enacted national soda taxes including Barbados, Belgium, Chile, Dominica, France, Hungary, Kiribati, Mauritius, Mexico, and Tonga.  Will the US have any competition for last place on this list? Oddly simple internet searches have not turned up any one organization that is solely advocating for passage of these laws in the US. A poll that Harvard conducted with Politico in 2017 reported that 57% of respondents supported taxing soda and other sugar sweetened drinks to raise money for preschool and children’s health programs that address obesity. 
The Center for Science in the Public Interest (CSPI) characterized industry opposition to these taxes:
“Big Soda’s campaign to preempt local soda taxes using ballot initiatives in Washington State and Oregon is much like its campaign to get people to drink soda in the first place: big, loud, expensive, and—most of all—misleading. The industry knows that communities are increasingly turning to soda taxes to address diabetes and obesity and raise revenue for community needs. That’s why it spent millions falsely reframing soda taxes as taxes on ‘groceries.’”
CSPI goes on to make a long-term commitment:
“We will work to ensure that, in the years ahead, more local communities, state legislatures, and, eventually, Congress enact taxes on soda and other sugary drinks. Just as the tobacco industry delayed public health gains but lost in the end, the writing is on the wall for Big Soda. Regardless of how the votes come out today, it’s the long game that matters.”
Would it not be inspiring if our profession could step up and
make a similar commitment? Aren’t we all
a bit embarrassed to admit that both CSPI and even the APA are ahead of us in
advocating for a sensible public health policy?
They are leaving us behind. We
should be the ones leading the charge.
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U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015. http://health.gov/dietaryguidelines/2015/guidelines/. Accessed February 4, 2019.
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The Impact of Soda Taxes: Pass-through, Tax Avoidance, and Nutritional Effects. Unpublished 2019
Roache SA, Gostin LO. The Untapped Power of Soda Taxes: Incentivizing Consumers, Generating Revenue, and Altering Corporate Behavior. Int J Health Policy Manag. 2017 Sep; 6(9): 489–493.