Study Reignites Calls for Worldwide Controls on Sugary Drinks

Marcia Frellick

July 02, 2015

A report that blames sugary drinks for almost 200,000 deaths worldwide every year has just been published in Circulation, with the authors emphasizing "a need for strong, global prevention programs."

"This isn't just rich countries," said senior author Dariush Mozaffarian, MD, Dr PH, dean of the Friedman School of Nutrition Science and Policy at Tufts University, in Boston, Massachusetts. "It's especially happening in the middle-income countries."

The research, based on surveys of more than 600,000 people, was first presented as an abstract at the American Heart Association Council on Epidemiology and Prevention in 2013, as reported by Medscape Medical News.

The results, as published by Gitanjali Singh, PhD, also of the Friedman School at Tufts University, and colleagues, are essentially the same as those reported in the abstract.

Worldwide, the study's model estimated 184,000 deaths per year attributable to sugar-sweetened beverages (SSBs): 133,000 from diabetes; 45,000 from cardiovascular disease; and 6450 from cancers. It also attributes 8.5 million disability-adjusted life-years (DALYs) worldwide to the consumption of sugary beverages.

Middle-income countries had 70.9% of the SSB-related deaths, followed by 24.1% in high-income countries and 5% in low-income countries.

The lowest proportional death rate was among Japanese people older than 65 (1%) and the highest was in Mexicans younger than 45 (30%). Among the most populous countries, the death rate related to the beverages was highest in Mexico in all age-sex groups, followed by the United States, Indonesia, and Brazil.

And among the 20 countries with the highest SSB-related deaths, at least eight were in Latin America and the Caribbean across all age and sex subgroups.

Climate Changing in Some Areas

This study is being published, however, in a rapidly changing political climate in some countries, with a number of multipronged approaches being tried in an attempt to reduce consumption of sugary drinks.

The US state of Vermont, for example, began imposing a 6% sales tax on some soft drinks on July 1. And in 2014, Berkeley, California, became the first US city to pass a sugary-drink tax. Several fast-food chains have dropped sugary drinks from kids' meals in the United States, and the California legislature considered, then rejected, putting warning labels on the drinks.

But Jane Chiang, MD, senior vice president of medical affairs and community information at the American Diabetes Association (ADA), says although efforts are increasing in some countries, heightened awareness globally is still an elusive concept.

"I think consumption is going up," she told Medscape Medical News. "Overall in the [United States] and some of the other developed countries, there's more awareness around sugar-sweetened beverages…[but] I don't know that's the case in, for example, in Mexico, which is a country they cited in this report, and in Latin [American] and Caribbean countries."

The authors focused on sugar-sweetened sodas, fruit drinks, sports/energy drinks, sweetened iced tea, or homemade beverages such as frescas (popular in Latin American and Caribbean countries), but they excluded 100% fruit juice.

However, Dr Chiang said she would also include juice in targets for reduced consumption.

"People think fruit juice is healthy, but when you actually read the label, there's a lot of sugar in that as well," she says. As to level of consumption, "it really needs to be none or very minimal — even those beverages that say they are 100% juice."

Talking With Patients

She recommends that physicians ask all patients about their level of sugar-sweetened beverage consumption and then work together to set gradual goals to eliminate them. Just having the conversation is important, she stressed.

"They may feel that if you didn't bring it up, it's okay," she said.

She also said that education should start with children.

The study points out that proportional mortality due to the drinks "is remarkably high among younger adults, exceeding one in 10 of all diabetes and obesity-related deaths in nearly every region of the world. Younger adults also constitute the largest proportion of the workforce in most countries, producing tremendous economic losses related to SSB intakes in these age groups."

Dr Mozaffarian agrees with educating the young: "Diet is the number-one cause of poor health in this country, and so all physicians should be talking to their patients," he told Medscape Medical News. "All pediatricians, especially, should be talking to their patients."

Those conversations with patients should happen at every visit and should be prioritized at the same level as, if not higher than, questions about smoking, he says, noting, "Twenty percent of people smoke, but everybody eats."

However, he said that without changes in policy, education may have minimal impact — auto safety and food-protection regulations are examples of policies saving people from themselves.

"Diet is a complex system, and relying on an individual person to navigate that would be like, in the 1920s, saying that people are dying in car accidents, so let's rely on teaching the driver how to drive instead of improving the cars and improving the roads," he says.

Eliminating sugary drinks won't eliminate diet-related disease alone, "but it's a really important step," he said, noting that education on healthy replacements, as well as healthy food, is also vital.

The estimates of consumption reported in the study came from 62 dietary surveys including 611,971 individuals from 51 countries conducted between 1980 and 2010. Researchers used a comparative risk-assessment model that compared geographical, gender, and age variation in SSB consumption, and the resultant effects on body mass index (BMI), diabetes, and other disease outcomes, as well as cause-specific mortality.

Although most of the deaths in the study were from diabetes, the work appears in Circulation, the journal of the American Heart Association, because of the interconnectedness of obesity, hypertension, dyslipidemia, diabetes, and heart disease.

One of the AHA's 2020 strategic impact goals is healthy diet, and one of the metrics for that is eliminating sugar-sweetened beverages, Dr Mozaffarian noted.

Dr Mozaffarian reports ad hoc travel reimbursement and/or honoraria for one-time scientific presentations or reviews on diet and cardiometabolic diseases from Bunge and Haas Avocado Board; ad hoc consulting fees from Nutrition Impact, Amarin, AstraZeneca, Boston Heart Diagnostics, GOED, and Life Sciences Research Organization; and being a member of the Unilever North America scientific advisory board. The coauthors report they have no relevant financial relationships, as does Dr Chiang.

Circulation. Published online June 29 2015. Abstract

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