Last Nail in the Coffin for Sugar-Sweetened Beverages

Now Let's Focus on the Hard Part

Alice H. Lichtenstein, DSc


Circulation. 2019;139(18):2126-2128. 

In This Article

Current Landscape and Tackling the Problem

With these findings taken together, what we now have is a long-term, prospective, comprehensive assessment of both SSB and ASB intake and mortality, the most extensive to date. The limited generalizability of the cohorts should not detract from the findings because no indications have been identified to suggest that individuals with different demographic characteristics would respond differently. Although attenuated by certain covariates, the findings, for the most part, remained robust. An important observation is that the data were consistent across all categories of SSBs. The findings clearly demonstrated that substitution of ASB for SSB would be predicted to have a positive impact on mortality.

So where are we with respect to SSB? In the 21st century, there appears to be no benefit to consuming SSBs, and there appears to be benefit from not consuming SSBs. However, there is some reason for caution. In the past, when the nutrition community has overemphasized an isolated dietary component or single nutrient rather than the whole dietary pattern, we have met with disappointing outcomes at best (eg, vitamin E,[8] vitamin D[9]) and adverse outcomes at worst (eg, low-fat diets[10] and β-carotene[11]). However, SSBs are unique. Besides contributing, for the most part, unneeded dietary energy and rapidly absorbable simple carbohydrate, unless fortified, they are devoid of essential nutrients. The conclusions of these new data[4] and the vast majority of prior work[12,13] are unusually consistent for the field of nutrition. What should we do with these data? To a certain extent, as a community, we can take the high road about beverage recommendations: Drink water (or flavored water) in place of SSBs. However, continuing this simple approach would be disingenuous because we know that it has not worked well in the past and there is little reason to expect that it will work well in the future, particularly for the subgroups of the population bearing the largest burden from the adverse effects of SSBs. Why so disenchanted? Consistently, starting with the Dietary Goals for Americans published in 1977 and through various editions of the Dietary Guidelines for Americans starting in 1980, there has been a recommendation to reduce sugar intake.[14] The 2000 edition of the Dietary Guidelines for Americans intentionally added specifically to this recommendation by advocating a reduction in SSB intake. Nevertheless, as demonstrated in the NHS and HPFS cohorts, SSB intake increased until the turn of this century, although it is now declining.[4] Even with this decline, intake levels are still at alarmingly high levels.

Knowledge of and behavior concerning the adverse effects of SSB may not be as closely related as expected.[15] Traditionally, we have relied on recommendations from the government or health advocacy organizations to change behavior, frequently with disappointing effects. Other approaches have been more successful but do not provide a viable template for SSBs. Removal of the major source of dietary trans fatty acids from the food supply, partially hydrogenated fat, and substitution of vegetable oils did not affect the appearance or taste of food. Hence, the phase-out of partially hydrogenated fat essentially went under the radar, and for the average person, the default option became the healthier option. In contrast to trans fatty acids, removing sugar from foods and beverages alters their appearance and taste. In addition, from a young age, we are habituated to sweet (eg, fruit juice), and from a teleological perspective, some have hypothesized that preferences for sweet resulted in our survival, coupled with an aversion to bitter and sour.

So where do we go from here? Rather than generating more data on the adverse effects of SSBs, we need to move on to the harder task and aim to make greater strides in understanding what the motivation is for choosing SSBs despite knowledge of the risks. We need to go out of our comfort zones and partner more closely with our behavioral colleagues. We need to develop new approaches to understand what drives the choice of SSBs. These new understandings may be transferable to other areas of adverse health behaviors, or they may be unique to SSB. At this point, that is not important. What is important is that we have identified a problem, and we need to focus a concerted effort on fixing it permanently.