LIQUID CANDY: HOW SOFT DRINKS ARE HARMING
AMERICANS' HEALTH

by Michael F. Jacobson, Ph. D.

			TOPICS
				Soaring Consumption of Soft Drinks
				Nutritional Impact of Soft Drinks
				Health Impact of Soft Drinks
				Aggressive Marketing of Soft Drinks
				Recommendations for Action

In 1942, when production of carbonated soft drinks was about 60 12-ounce servings per person, the American Medical Association's (AMA) Council on Foods and Nutrition stated: "From the health point of view it is desirable especially to have restriction of such use of sugar as is represented by consumption of sweetened carbonated beverages and forms of candy which are of low nutritional value. The Council believes it would be in the interest of the public health for all practical means to be taken to limit consumption of sugar in any form in which it fails to be combined with significant proportions of other foods of high nutritive quality." 1

By 1998, soft-drink production had increased by nine-fold and provided more than one-third of all refined sugars in the diet, but the AMA and other medical organizations now are largely silent. This review discusses the nutritional impact and health consequences of massive consumption of soft-drinks,2 particularly in teenagers.

SOARING CONSUMPTION OF SOFT DRINKS

Carbonated soft drinks account for more than 27 percent of Americans' beverage consumption.3 In 1997, Americans spent over $54 billion to buy 14 billion gallons of soft drinks. That is equivalent to more than 576 12-ounce servings per year or 1.6 12-ounce cans per day for every man, woman, and child.4 That is also more than twice the amount produced in 1974. Artificially sweetened diet sodas account for 24% of sales, up from 8.6% in 1970.5

Table 1.  Consumption of non-diet soft drinks by 12- to 19-year-olds (ounces per day) and percent of caloric intakes (all figures include non-drinkers).

Calculated from U.S. Dept. Agr. Nationwide Food Consumption Survey, 1977-78;  Continuing Survey of Food Intakes by Individual, 1987-88, 1994-96.

Children start drinking soda pop at a remarkably young age, and consumption increases through young adulthood. One fifth of one- and two-year-old children consume soft drinks.6 Those toddlers drink an average of seven ounces -- nearly one cup -- per day. Toddlers' consumption changed little between the late 1970s and mid 1990s.

Table 2.  Consumption of regular and diet soft drinks by 12- to 19-year-olds (excludes non-drinkers).

U.S. Dept. Agr. Nationwide Food Consumption Survey, 1977-78;  Continuing Survey of Food Intakes by Individual, 1987-88, 1994-96.

Almost half of all children between 6 and 11 drink soda pop, with the average drinker consuming 15 ounces per day. That's up slightly from 12 ounces in 1977-78.

The most avid consumers of all are 12- to 29-year-old males. Among boys 12 to 19, those who imbibe soda pop drink an average of almost 2.5 12-ounce sodas (28.5 ounces) per day. Teenage girls also drink large amounts of pop. Girls who drink soft drinks consume about 1.7 sodas per day. (Women in their twenties average slightly more: two 12-ounce sodas per day.)  (See Tables 1 and 2)

In a new analysis of diet-intake data, soft-drink consumption by 13- to 18-year-olds was examined (the results cannot be compared directly to the data shown for 12- to 19-year-olds because slightly different methods were used).  This analysis identified how much soda pop is consumed by how many teens.   For instance, one-fourth of 13- to 18-year-old male pop-drinkers drink 2.5 or more cans per day, and one out of 20 drinks five cans or more.7 (See Table 3)  One-fourth of 13- to 18-year-old female pop-drinkers drink about two cans or more per day, and one out of twenty drinks three cans or more.8  (Actual intakes may well be higher, because many survey participants  tend to underestimate quantities of "bad" foods consumed.)

Table 3.  Consumption of regular and diet soft drinks by 13- to 18-year olds (ounces per day; excludes non-drinkers)

Percentile calculations by Environ, Inc.; data from USDA, CSFII, Figures for 1977-78 calculated from P.M. Guenther, J. Am. Diet. Assoc. 1986;86:493-9.

By contrast, twenty years ago, the typical (50th-percentile) 13- to 18-year-old consumer of soft drinks (boys and girls together) drank .75 of a can per day, while the 95th-percentile teen drank 2.25 cans. That's slightly more than one-half of current consumption.

One reason, aside from the ubiquitous advertising, for increasing consumption is that the industry has steadily increased container sizes. In the 1950s, Coca-Cola's 6.5-ounce bottle was the standard serving. That grew into the 12-ounce can, and now those are being supplanted by 20-ounce bottles (and the 64-ounce Double Gulp at 7-Eleven stores). The larger the container, the more beverage people are likely to drink, especially when they assume they are buying single-serving containers.

Also, prices encourage people to drink large servings. For instance, at McDonald's restaurants a 12-ounce ("child size") drink costs 89 cents, while a drink 250% larger (42-ounce "super size") costs only 79% more ($1.59).9 At Cineplex Odeon theaters, a 20-ounce ("small") drink costs $2.50, but one 120% larger (44-ounce "large") costs only 30% more ($3.25).10

NUTRITIONAL IMPACT OF SOFT DRINKS

Regular soft drinks provide youths and young adults with hefty amounts of sugar and calories. Both regular and diet sodas affect Americans' intake of various minerals, vitamins, and additives.

Sugar Intake
Carbonated drinks are the single biggest source of refined sugars in the American diet.11 According to dietary surveys,12 soda pop provides the average American with seven teaspoons of sugar per day, out of a total of 20 teaspoons. Teenage boys get 44% of their 34 teaspoons of sugar a day from soft drinks. Teenage girls get 40% of their 24 teaspoons of sugar from soft drinks. Because some people drink little soda pop, the percentage of sugar provided by pop is higher among actual drinkers.

The U.S. Department of Agriculture (USDA) recommends that people eating 1,600 calories a day not eat more than six teaspoons a day of refined sugar, 12 teaspoons for those eating 2,200 calories, and 18 teaspoons for those eating 2,800 calories.13,14 To put those numbers in perspective, consider that the average 12- to 19-year-old boy consumes about 2,750 calories and 11⁄2 cans of soda with 15 teaspoons of sugar a day; the average girl consumes about 1,850 calories and one can with ten teaspoons of sugar. Thus, teens just about hit their recommended sugar limits from soft drinks alone. With candy, cookies, cake, ice cream, and other sugary foods, most exceed those recommendations by a large margin.

Calorie Intake
Lots of soda pop means lots of sugar means lots of calories. Soft drinks are the fifth largest source of calories for adults.15 They provide 5.6% of all the calories that Americans consume.16 In 12- to 19-year-olds, soft drinks provide 9% of boys' calories and 8% of girls' calories.17 Those percentages are triple (boys) or double (girls) what they were in 1977-78. (See Table 1) Those figures include teens who consumed little or no soda pop.

For the average 13- to 18-year-old boy or girl drinker, soft drinks provide about 9% of calories. Boys and girls in the 75th percentile of consumption obtained 12% of their calories from soft drinks, and those in the 90th percentile about 18% of their calories.

Nutrient Intakes
Many nutritionists state that soft drinks and other calorie-rich, nutrient-poor foods can fit into a good diet. In theory, they are correct, but, regrettably, they ignore the fact that most Americans consume great quantities of soft drinks and meager quantities of healthful foods. One government study found that only 2% of 2- to 19-year-olds met all five federal recommendations for a healthy diet.18 USDA's Healthy Eating Index found that on a scale of 0-100, teenagers had scores in the low 60s (as did most other age-sex groups). Scores between 51 and 80 indicate that a diet "needs improvement."19

Dietary surveys of teenagers found that in 1996:

	Only 34% of boys and 33% of girls consumed the number of servings of vegetables recommended by USDA's Food Pyramid.
	Only 11% of boys and 16% of girls consumed the recommended amount of fruit.
	Only 29% of boys and 10% of girls consumed the recommended amount of dairy foods.
	Most boys and girls did not meet the recommended amounts of grain and protein foods.

Those surveys also found that few 12- to 19-year-olds consumed recommended amounts of certain nutrients, including:

	calcium: only 36% of boys and 14% of girls consumed 100% of the Recommended Dietary Allowance (RDA).
	vitamin A: only 36% of boys and 31% of girls consumed 100% of the RDA.
	magnesium: only 34% of boys and 18% of girls consumed 100% of the RDA.
	Most boys and girls did not meet the recommended amounts of grain and protein foods.

As teens have doubled or tripled their consumption of soft drinks, they cut their consumption of milk by more than 40%. Twenty years ago, boys consumed more than twice as much milk as soft drinks, and girls consumed 50% more milk than soft drinks. By 1994-96, both boys and girls consumed twice as much soda pop as milk (and 20- to 29-year-olds consumed three times as much). Teenage boys consumed about 2 2/3 cups of carbonated soft drinks per day but only 1.25 cups of fluid milk. Girls consumed about 1.5 cups per day of soft drinks, but less than 1 cup of milk. Compared to adolescent nonconsumers, heavy drinkers of soda pop (26 ounces per day or more) are almost four times more likely to drink less than one glass of milk a day.20

In 1977-78, teenage boys and girls who frequently drank soft drinks consumed about 20% less calcium than non-consumers. Heavy soft-drink consumption also correlated with low intake of magnesium, ascorbic acid, riboflavin, and vitamin A, as well as high intake of calories, fat, and carbohydrate.21 In 1994-96, calcium continued to be a special problem for female soft-drink consumers.22

HEALTH IMPACT OF SOFT DRINKS

The soft-drink industry has consistently portrayed its products as being positively healthful, saying they are 90% water and contain sugars found in nature. A poster that the National Soft Drink Association has provided to teachers states: "As refreshing sources of needed liquids and energy, soft drinks represent a positive addition to a well-balanced diet....These same three sugars also occur naturally, for example, in fruits....In your body it makes no difference whether the sugar is from a soft drink or a peach."23

M. Douglas Ivester, Coca-Cola's chairman and CEO, defending marketing in Africa, said, "Actually, our product is quite healthy. Fluid replenishment is a key to health....Coca-Cola does a great service because it encourages people to take in more and more liquids."24

In fact, soft drinks pose health risks both because of what they contain (for example, sugar and various additives) and what they replace in the diet (beverages and foods that provide vitamins, minerals, and other nutrients).

Obesity
Obesity increases the risk of diabetes and cardiovascular disease and causes severe social and psychological problems in millions of Americans. Between 1971-74 and 1988-94, obesity rates in teenage boys soared from 5% to 12% and in teenage girls from 7% to 11%. Among adults, between 1976-80 and 1988-94, the rate of obesity jumped by one-third, from 25% to 35%.25

Numerous factors -- from lack of exercise to eating too many calories to genetics -- contribute to obesity. Soda pop adds unnecessary, non-nutritious calories to the diet, though it has not been possible to prove that it (or any other individual food) is responsible for the excess calories that lead to obesity. However, one recent study found that soft drinks provide more calories to overweight youths than to other youths. The difference was most striking among teenage boys: Soda pop provides 10.3% of the calories consumed by overweight boys, but only 7.6% of calories consumed by other boys. There was no consistent pattern of differences with regard to intake of calories, fat, or several other factors.26

Obesity rates have risen in tandem with soft-drink consumption, and heavy consumers of soda pop have higher calorie intakes.27 While those observations do not prove that sugary soft drinks cause obesity (heavy consumers may exercise more and need more calories), heavy consumption is likely to contribute to weight gain in many consumers.

Regardless of whether soda pop (or sugar) contributes to weight gain, nutritionists and weight-loss experts routinely advise overweight individuals to consume fewer calories -- starting with empty-calorie foods such as soft drinks. The National Institutes of Health recommends that people who are trying to lose or control their weight should drink water instead of soft drinks with sugar.28

Bones and Osteoporosis
People who drink soft drinks instead of milk or other dairy products likely will have lower calcium intakes. Low calcium intake contributes to osteoporosis, a disease leading to fragile and broken bones.29 Currently, 10 million Americans have osteoporosis. Another 18 million have low bone mass and are at increased risk of osteoporosis. Women are more frequently affected than men. Considering the low calcium intake of today's teenage girls, osteoporosis rates may well rise.

The risk of osteoporosis depends in part on how much bone mass is built early in life. Girls build 92% of their bone mass by age 18,30 but if they don't consume enough calcium in their teenage years they cannot "catch up" later. That is why experts recommend higher calcium intakes for youths 9 to 18 than for adults 19 to 50. Currently, teenage girls are consuming only 60% of the recommended amount, with soft-drink drinkers consuming almost one-fifth less than nonconsumers.31

While osteoporosis takes decades to develop, preliminary research suggests that drinking soda pop instead of milk can contribute to broken bones in children. One study found that children 3 to 15 years old who had suffered broken bones had lower bone density, which can result from low calcium intake.32

Tooth Decay
Refined sugar is one of several important factors that promote tooth decay (dental caries). Regular soft drinks promote decay because they bathe the teeth of frequent consumers in sugar-water for long periods of time during the day. An analysis of data from 1971-74 found a strong correlation between the frequency of between-meal consumption of soda pop and dental caries.33 (Those researchers considered other sugary foods in the diet and other variables.) Soft drinks appear to cause decay in certain surfaces of certain teeth more than in others.34

Tooth-decay rates have declined considerably in recent decades, thanks to such preventive factors as fluoride-containing toothpaste, fluoridated water, tooth sealants, and others. Nevertheless, caries remains a problem for some people. A large survey in California found that children (ages 6 to 8, 15) of less-educated parents have 20% higher rates of decayed and filled teeth.35 A national study found that African-American and Mexican-American children (6 to 18 years old) are about twice as likely to have untreated caries as their white counterparts.36 For people in high-risk groups, prevention is particularly important.

To prevent tooth decay, even the Canadian Soft Drink Association recommends limiting between-meal snacking of sugary and starchy foods, avoiding prolonged sugar levels in the mouth, and eating sugary foods and beverages with meals. Unfortunately, many heavy drinkers of soft drinks violate each of those precepts.

Heart Disease
Heart disease is the nation's number-one killer. Some of the most important causes are diets high in saturated and trans fat and cholesterol; cigarette smoking; and a sedentary lifestyle. In addition, in many adults a diet high in sugar may also promote heart disease.

High-sugar diets may contribute to heart disease in people who are "insulin resistant." Those people, an estimated one-fourth of adults, frequently have high levels of triglycerides and low levels of HDL ("good") cholesterol in their blood. When they eat a diet high in carbohydrates, their triglyceride and insulin levels rise. Sugar has a greater effect than other carbohydrates.37 The high triglyceride levels are associated with a higher risk of heart disease.38 It would make sense for insulin-resistant people, in particular, to consume low levels of regular soft drinks and other sugary foods. Research is needed on insulin resistance in adolescents.

Kidney Stones
Kidney (urinary) stones are one of the most painful disorders to afflict humans and one of the most common disorders of the urinary tract. According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), a unit of the National Institutes of Health, more than 1 million cases of kidney stones were diagnosed in 1985.39 NIDDK estimates that 10 percent of all Americans will have a kidney stone during their lifetime. Several times more men, frequently between the ages of 20 and 40, are affected than women. Young men are also the heaviest consumers of soft drinks.

After a study suggested a link between soft drinks and kidney stones, researchers conducted an intervention trial.40 That trial involved 1,009 men who had suffered kidney stones and drank at least 5 1/3 ounces of soda pop per day. Half the men were asked to refrain from drinking pop, while the others were not asked. Over the next three years drinkers of Coca-Cola and other cola beverages acidified only with phosphoric acid who reduced their consumption (to less than half their customary levels) were almost one-third less likely to experience recurrence of stones. Among those who usually drank soft drinks acidified with citric acid (with or without phosphoric acid), drinking less had no effect. While more research needs to be done on the cola-stone connection, the NIDDK includes cola beverages on a list of foods that doctors may advise patients to avoid.

Additives: Psychoactive Drug, Allergens, and More
Several additives in soft drinks raise health concerns. Caffeine, a mildly addictive stimulant drug, is present in most cola and "pepper" drinks, as well as some orange sodas and other products. Caffeine's addictiveness may be one reason why six of the seven most popular soft drinks contain caffeine.41 Caffeine-free colas are available, but account for only about 5% of colas made by Coca-Cola and Pepsi-Cola.42 On the other hand, Coca-Cola and other companies have begun marketing soft drinks, such as Surge, Josta, and Jolt, with 30% to 60% more caffeine than Coke and Pepsi.

In 1994-96, the average 13- to 18-year-old boy who drank soft drinks consumed about 12/3 cans per day. Those drinking Mountain Dew would have ingested 92 mg of caffeine from that source (55 mg caffeine/12 ounces). That is equivalent to about one six-ounce cup of brewed coffee. Boys in the 90th-percentile of soft-drink consumption consume as much caffeine as is in two cups of coffee; for girls the figure is 1.5 cups of coffee.

One problem with caffeine is that it increases the excretion of calcium in urine.43 Drinking 12 ounces of caffeine-containing soft drink causes the loss of about 20 milligrams of calcium, or two percent of the U.S. RDA (or Daily Value). That loss, compounded by the relatively low calcium intake in girls who are heavy consumers of soda pop, may increase the risk of osteoporosis.

Caffeine can cause nervousness, irritability, sleeplessness, and rapid heart beat.44 Caffeine causes children who normally do not consume much caffeine to be restless and fidgety, develop headaches, and have difficulty going to sleep.45 Also, caffeine's addictiveness may keep people hooked on soft drinks (or other caffeine-containing beverages). One reflection of the drug's addictiveness is that when children age six to 12 stop consuming caffeine, they suffer withdrawal symptoms that impair their attention span and performance.46

Several additives used in soft drinks cause occasional allergic reactions. Yellow 5 dye causes asthma, hives, and a runny nose.47 A natural red coloring, cochineal (and its close relative carmine), causes life-threatening reactions.48 Dyes can cause hyperactivity in sensitive children.49

In diet sodas, artificial sweeteners may raise concerns. Saccharin, which has been replaced by aspartame in all but a few brands, has been linked in human studies to urinary-bladder cancer and in animal studies to cancers of the bladder and other organs.50 Congress has required products made with saccharin to bear a warning label. The safety of acesulfame-K, which was approved in 1998 for use in soft drinks, has been questioned by several cancer experts.51 Also, aspartame should be better tested.

AGGRESSIVE MARKETING OF SOFT DRINKS

Soft-drink companies are among the most aggressive marketers in the world. They have used advertising and many other techniques to increase sales.

Soft-drink advertising budgets dwarf all advertising and public-service campaigns promoting the consumption of fruits, vegetables, healthful diets, and low-fat milk. In 1997, Coca-Cola, which accounts for 44%52 of the soft-drink market in the U.S., spent $277 million on advertising and the four major companies $631 million. Between 1986 and 1997 those companies spent $6.8 billion on advertising.53

Companies make sure their products are always readily accessible. Thus, in 1997, 2.8 million soft-drink vending machines dispensed 27 billion drinks worth $17.5 billion.54 Coca-Cola's soft drinks are sold at two million stores, more than 450,000 restaurants, and 1.4 million vending machines and coolers.55

Table 4.  Beverage prices

Prices at Washington-are supermarkets, September, 1998.

The major companies target children aggressively (though, to their credit, they have not gone after 4-year-olds by advertising on Saturday-morning television). Pepsi advertises on Channel One, a daily news program shown in 12,000 schools.56 Companies inculcate brand loyalties in children and boost consumption by paying school districts and others for exclusive marketing agreements. For instance, Dr Pepper paid the Grapevine-Colleyville, Texas, School District $3.45 million for a ten-year contract (it includes rooftop advertising to reach passengers in planes landing at the nearby Dallas/Ft. Worth Airport).57 To reach youths after school, Coca-Cola is paying $60 million over ten years to the Boys & Girls Clubs of America for exclusive marketing rights in more than 2,000 clubs.58

In one of the most despicable marketing gambits, Pepsi, Dr Pepper, and Seven-Up encourage feeding soft drinks to babies by licensing their logos to a major maker of baby bottles, Munchkin Bottling, Inc. Infants and toddlers are four times likelier to be fed soda pop out of those bottles than out of regular baby bottles.59

Also fueling soft-drink sales is the low cost of the sugar-water-additive products. (See Table 4) Supermarket brands are particularly cheap, easily getting as low as 28 cents per quart, but even Coca-Cola and Pepsi-Cola are available for 33 cents per quart when on special. Milk costs two to three times as much, about 70 to 95 cents per quart.

Moreover, in recent years, inflation has had a greater effect on the price of milk than of soft drinks. Between 1982-84 and 1997 the Consumer Price Index rose 2.3 times as much for milk as for soft drinks.60

The soft-drink industry is aiming for continued expansion in coming years. Thus, the president of Coca-Cola bemoans the fact that his company accounts for only 1 billion out of the 47 billion servings of all beverages that earthlings consume daily.61 The company's goal is to: "make Coca-Cola the preferred drink for any occasion, whether it's a simple family supper or a formal state dinner. . . . [T]o build pervasiveness of our products, we're putting ice-cold Coca-Cola classic and our other brands within reach, wherever you look: at the supermarket, the video store, the soccer field, the gas station -- everywhere."62

RECOMMENDATIONS FOR ACTION?

In part because of powerful advertising, universal availability, and low price, and in part because of disinterest on the part of many nutritionists and other health professionals, Americans have come to consider soft drinks a routine snack and a standard, appropriate part of meals instead of an occasional treat, as they were treated several decades ago. Moreover, many of today's younger parents grew up with soft drinks, see their routine consumption as normal, and so make little effort to restrict their children's consumption of them.

It is a fact, though, that soft drinks provide enormous amounts of sugar and calories to a nation that does not meet national dietary goals and that is experiencing an epidemic of obesity. The replacement of milk by soft drinks in teenage girls' diets portends continuing high rates of osteoporosis. Soft drinks may also contribute to dental problems, kidney stones, and heart disease. Additives may cause insomnia, behavioral problems, and allergic reactions and may increase slightly the risk of cancer.

The industry promises that it will be doing everything possible to persuade even more Americans to drink even more soda pop even more often. Parents and health officials need to recognize soft drinks for what they are -- liquid candy -- and do everything possible to return those beverages to their former, reasonable role as an occasional treat.

	Individuals and families should consider how much soda pop they are drinking and reduce consumption accordingly. Parents should stock their homes with healthful foods and beverages that family members enjoy.
	Physicians, nurses, and nutritionists routinely should ask their patients how much soda pop they are drinking and advise them, if appropriate, of dietary changes to make.
	Organizations concerned about women's and children's health, dental and bone health, and heart disease should collaborate on campaigns to reduce soft-drink consumption.
	Local, state, and federal governments should be as aggressive in providing water fountains in public buildings and spaces as the industry is in placing vending machines everywhere.
	State and local governments should considering taxing soft drinks, as Arkansas, Tennessee, Washington, and West Virginia already do. Arkansas raised $40 million in fiscal year 1998 from that tax. 63 If all states taxed soft drinks at Arkansas' rate (2 cents per 12-ounce can), they could raise $3 billion annually. Those revenues could fund campaigns to improve diets, build exercise facilities (bike paths, swimming pools, etc.), and support physical-education programs in schools.
	Local governments could require calorie listings on menu boards at fast-food outlets and on vending machines to sensitize consumers to the nutritional "cost" of sugared soft drinks and other foods.
	School systems and other organizations catering to children should stop selling soft drinks, candy, and similar foods in hallways, shops, and cafeterias.
	School systems and youth organizations should not auction themselves off to the highest bidder for exclusive soft-drink marketing rights. Those deals profit the companies and schools at the expense of the students' health.
	The National Academy of Sciences or Surgeon General should review the impact of current and projected levels of soft-drink (and sugar) consumption on public health.
	Soft-drink companies voluntarily should not advertise to children and adolescents. Labels should advise parents that soft drinks may replace lowfat milk, fruit juice, and other healthy foods in the diets of children and adolescents.
	Scientific research should explore the role of heavy consumption of soft drinks (and sugar) in nutritional status, obesity, caries, kidney stones, osteoporosis, and heart disease.

END NOTES

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