The first time I went to the dentist I had 9 cavities. My father said I was drinking too much Coca-Cola. I don't remember drinking any Coca-Cola. It was expensive and it wasn't in our house. Anyway I learned early about how it rots your teeth. Generations of science fair projects have included one where the grammar school scientist put a tooth in a cup of Coca-Cola and demonstrated that the tooth putrefied after a certain length of time. This probably shouldn't actually work because it is the bacteria that drink the Coca-Cola that rot your teeth and not the Coca-Cola directly. Later, during the 60's Coca-Cola personified Yankee imperialism. Then there was the wrong, but still widely believed, assertion that sugar, not to mention caffeine, causes hyperactivity in children. You'd think that would make them skinny. The modern era of sugared beverage indictment was launched in 1997 when a pediatric primary care practice in Schoharie county, a rural community in upstate New York, reported a connection between excessive fruit juice consumption and short stature and obesity in preschool-aged children.(1) A total of 225 children, 2 or 5 years old, who were scheduled for a check-up, were included. They found that those kids whose parents reported that they drank more than 12oz/day of fruit juices were shorter and fatter on average than the kids who didn't. They stated in their conclusion that, "Parents and care takers should limit young children's consumption of fruit juices to less than 12oz/day." In the introduction to this study, these authors cited a report of 8 children who were found to be failing to thrive because of excess fruit juice consumption.(2) However short stature and obesity doesn't conform to the obesity epidemic because obese children are generally taller than average. In a later report this same group found that the obesity relationship to juice intake only happened with apple juice(3) and others have been unable to find any association between fruit juices of any kind and obesity(4,5). A review of the literature co-authored by the dean of obesity epidemiology Dr.Frank Hu, Associate Professor of Nutrition and Epidemiology at Harvard School of Public Health and Director of the Boston Nutrition and Obesity Research Center Epidemiology and Genetics Core and etc....,(6) was published in 2006. They carefully examine 15 cross-sectional, 10 prospective and 5 experimental studies, selected because they had good methods. These studies almost consistently show that children and adults who drink more sugar sweetened beverages are fatter; if they start drinking more SSB they get fatter; and if they stop drinking SSB they don't get as fat. In 2007 another meta-analysis of 88 studies (7) "examined the association between soft drink consumption and nutrition and health outcomes.." They "found clear associations of soft drink intake with increased energy intake and body weight. Soft drink intake also was associated with lower intakes of milk, calcium, and other nutrients and with an increased risk of several medical problems like diabetes. Study design significantly influenced results: larger effect sizes were observed in studies with stronger methods according to these reviewers. Several other factors also moderated effect sizes, among them gender, age, and beverage type. Finally, studies funded by the food industry reported significanly smaller effects than did non-industry funded studies. According to these authors, "Recommendations to reduce population soft drink consumption are strongly supported by the available science." This theory about SSB ties in with the point of view that carbohydrates are the enemy. But SSB are an even more pernicious form of carbohydrate because they have a high glycemic index and seem to go under the radar of our satiety signals according to this point of view. Supporting this theory is a study (8) in which subjects ate a prescribed amount of sugar in either the form of jelly beans or soda. During the jelly bean phase, they compensated by reducing intake of other foods, but there was no such compensation during the soda phase. Suggesting that there is still not enough evidence, three articles and 5 editorials about the perils of sugar-sweetened beverages (9-16) took up most of the pages in a more recent issue of The New England Journal of Medicine (NEJM) in 2012, on the eve of the election. That issue also contained articles by Barack Obama and Mitt Romney about their respective visions of health care for this country. Those politicians couldn't help noticing the sugar story. The first article uses data from 6934 women in the Nurses' Health Study, which my wife is part of and 4423 men in the Health Professionals Follow-up Study, which my father was part of, and another collection of 21,740 women in the Women's Genome Health Study, that didn't include any relatives of mine. They tested whether a genetic predisposition to obesity was related to drinking sugar-sweetened beverages. (New genetics data has found 32 spot variations, called alleles, pronounced ah-LEELS, that are associated with obesity. These alleles are not all or none things like the gene for leptin. Rather they are each weakly associated with obesity, correlating with just a few percentage points of increased risk. We don't know what these variations in the gene map actually do to cause a slightly increased association with obesity. Furthermore, even taken all together they only account for a small amount of the variation in the size and shape of humans.) They found that these 32 obesity associated alleles were also associated with drinking more sugar-sweetened beverages in these adults. The number of subjects was not large enough to find an association with any particular allele, but 10 or more of any of these alleles were statistically associated with drinking more SSB. So what does that mean? "These data suggest that persons with greater consumption of SSB may be more susceptible to genetic effects on adiposity." Or, "persons with a greater genetic predisposition to obesity appeared to be more susceptible to the deleterious effects of SSB..." So what does that mean? It sounds like salt and hypertension. Salt has an effect on blood pressure that is much more marked in individuals who are apparently salt sensitive. The second study took place in Amsterdam. They took 641 normal weight 5 to 12 year olds and gave half of them an 8 oz can of a sugar-sweetened beverage or a similar sugar-free artificially sweetened beverage to take home everyday after school. Then they watched them for 18 months. Of the 477 children who kept this up for 18 months, the half that got sugar sweetened beverages gained 2.2 more pounds than the sugar free drink children. That difference was significant and they also got a little taller but that difference was not significant. The differential weight gain happened mostly in the first 6 months. Between 12 and 18 months there was no further increase in the difference and the differential was starting to narrow. But these were not obese kids and this amount of SSB exposure is much less that the quantities that American kids are reported to be drinking. The third study in this issue was by Dr. Ludwig et al.. They got 224 overweight and obese adolescents and gave half of them an intervention designed to get them to drink less SSB and compared them to the other half without intervention. The intervention consisted of providing free water and diet beverages and telling them not to drink SSB. They did the intervention for 1 year but then they followed them for another year. At the end of 1 year there was a difference of 4 lbs between the groups but at the end of 2 years there was no difference in weight or body fat. Did the intervention group stopped behaving during the second year? These authors say that there was still an important decrease in SSB consumption and total calories in that group compared to the control group. They also found that among the Hispanic kids considered separately there was still a significant difference in weight at the end of 2 years. Did the Hispanic kids continue to behave better? Do they have more of those obesity alleles? The preponderance of the punditry included in this NEJM issue is that we should develop recommendations and make policy that limits the consumption of SSB. So how does this idea that SSB are the cause of obesity, stack up against the long list that includes fats, carbohydrates more generally, portion sizes, calorie density, fast foods or eating out vs eating home, watching TV, etc.. etc..? Are SSB just part of all of the above? Dr. Hu, in his 2008 book Obesity Epidemiology, after examining all these culprits together with SSB, sumarizes, "Although diet is widely believed to play a major role in weight control, the impact of specific dietary factors remains elusive. Clearly, there is no 'magic bullet' for weight control. Rather, many individual dietary factors exert a modest effect on body weight, and over time, cumulative effects of small changes in daily energy balance lead to weight gain and obesity." (17, p292) Much less tempered are the views of certain proselytes, most notably Dr. David Ludwig, who seem to be saying they have found the magic bullet in SSB. David Ludwig received a PhD and an MD from Stanford University School of Medicine. He completed an internship and residency in pediatrics and a fellowship in pediatric endocrinology at Boston Children's Hospital. According to the web site for the Boston Children's Hospital at Harvard, "David Ludwig developed the Children's Optimal Weight for Life (OWL) Program --a multi-disciplinary care clinic dedicated to the evaluation and treatment of children who are overweight/obese. Not only does the program provide state-of-the-art care for overweight children, it also serves as a setting for clinical research to develop innovative treatments for pediatric obesity. He has also been the a principal or co-investigator of several epidemiological and clinical studies to identify dietary factors that contribute to obesity. His research has determined that: * A low-glycemic index diet may be as or more effective than the standard reduced-fat diet for weight loss in children and adolescents. * Consumption of soft drinks is directly related to obesity in children. * Fast food consumption is associated with factors that increase risk of childhood obesity. * Consumption of dairy products may offer protection against insulin resistance in overweight adults." Demonstrating a heavy investment in this idea of Dr. Ludwig and company are statements such as: "Sugar-sweetened beverages may be the single largest driver of the obesity epidemic," (18) especially if "may be" means "is." And math like: "For each extra can or glass of sugared beverage consumed per day, the likelihood of a child's becoming obese increases by 60%." The evidence for this math is one of the studies included in the meta-analyses above. (19). That math, in turn, leads to math like "... a penny/oz tax (on SSB) over 10 years would reduce sugary drink consumption by 15%, thus preventing 95,000 coronary heart events, 8,000 strokes and 26,000 premature deaths." (20) Some of the studies mentioned above including the one by Dr. Ludwig et al. show that the effect of SSB consumption is small and limited and not linear. Another 2008 meta-analysis (21), that did NOT show an association between drinking SSB and obesity has been dismissed because it was sponsored by the American Beverage Association, Coca-Cola Company and PepsiCo etc... But it has an interesting summary figure (figure 1) that demonstrates that Dr. Ludwig's report, which was sponsored in part by the Charles H Hood Foundation a dairy interest, is distinctly outlying. This deep commitment and activism of the anti-SSB people leads, furthermore, to some real problems. A lot of people seem to have gotton the message. A lot of diet Pepsi gets drunk. The increase in consumption of no-calorie artificially sweetened beverages has gone up in a tight correlation with the increase in obesity - at least as closely correlative with the obesity increase as the increase in consumption of sugar sweetened beverages. In response to evidence that diet sweeteners are associated with obesity Dr. Ludwig as spokesperson for the SSB-causes-obesity bandwaggon is compelled to offer explanation for why that may be. (22) Epidemiological evidence as well as more direct evidence of the association of diet drinks and obesity as cited by him in this editorial are probably reverse causality. That is, it is very hard not to contaminate this observed association with the fact that drinking diet soft drinks is going to be done more by people who are obese or legitimately afraid of getting obese. Still he offers some conjecture that maybe diet drinks are bad too. Maybe, he suggests, we should stick to, "..water, mineral waters, teas, and coffee.." I think people are already doing that too. I just wish they would drink tap water instead of the incredibley wasteful plastic bottled water. In a study (23) of these issues diet drinks or water were substituted for SSB in obese and overweight adults for 6 months. They found that the diet drink group lost 2.5%, the water group 2 % and the control group, who were monitored and given generic advice about diet and exercise but not provided with drinks or directions to substitute SSB, lost 1.8%. These differences were not significant. Also, it did not look like water was better than artificially sweetened diet drinks. So the idea that SSB are the root of all evil idea fails on the usual conundrums. Why can't we lose a lot of weight by not drinking SSB? Why do we ever stop getting fatter if we keep drinking Pepsi? Why is obesity permanent? If we have the magic bullet in hand, then severly obese children must represent child abuse and neglect, another example of the danger of this idea. Should child protective services ever be used to rescue obese children? A disturbing commentary co-authored by Dr. David Ludwig says "yes."(24) They say that in a case of childhood obesity that is so severe as to imperil a child's life, removing that child into foster care may be less risky than obesity surgery and "warrants discussion," citing an article that appeared in Pediatrics several years prior. (25) There it was stated: "In our opinion, removal of a (very obese) child from the home is justified when all 3 of the following conditions are present: 1. a high likelihood that serious imminent harm will occur; 2. a reasonable likelihood that coercive state intervention will result in effective treatment; and 3. the absence of alternative options for addressing the problem." Conditions 2 and 3 are only true if you believe in magic bullets. The American Society of Bariatric Physicians (ASBP) does not support the concept that state intervention to remove a child from his or her home is the proper way to address life threatening cases of childhood obesity. The ASBP believes that there are many factors involved in this problem that are beyond control by parents, foster or not. Also foster care would be adding insult to injury and would involve an overwhelming and increasing number of children if such a policy would ever be implemented. (26) Further reasoned arguments to this point of view have been advanced and replied to by Dr. Ludwig and company. (27) Then there is another of the standard conundrums. Why does obesity surgery work so well? What has that got to do with sugar? In a viewpoint together with 2 other authors, Dr Ludwig, (28) complains about a report that showed how well surgery works for obesity and prevention of type 2 diabetes. (29) Dr. Ludwig et al. complain that they really didn't compare diet and exercise with surgery because there wasn't nearly enough money and time spent making the non-surgery customers diet and exercise and anyway those customers didn't lose any weight. If they had lost weight then it would have worked just as well for curing their diabetes and would be a lot safer and cheaper. They contend that that's like comparing antibiotics to some other treatment for infection when the patients in the antibiotic group didn't take the antibiotics. Dr. Ludwig's point of view is more like trying to make one group of patients walk through fire and then saying that you can't compare that to another idea because none of the patients could or would walk through fire. Dr. Ludwig knows, I'm sure, about the abundant evidence that losing a lot of weight and keeping it off by dieting, is very painful and that the pain of weight loss never stops for the rest of your life or until you put the weight back on. He also knows that people who lose a lot of weight by surgery don't feel hungry and miserable and stressed. Dr. Ludwig says that people who get surgery also regain weight and some of them get back their diabetes. But the reference he cites for this has a graph showing that 10 years after gastric bypass these patients, on average, still have kept off 30% of their starting weight. (30) How do these Mr. Magoo's keep getting away with such poor vision. What is it about sugar sweetened beverages? In his editorial (22) about artificially sweetened beverages Dr. Ludwig says, "an 8-oz apple contains beneficial vitamins, minerals, and phytochemicals but fewer calories than an 2-oz portion of bread. Most fruits elicit a high level of satiety relative to calories ingested due to their low-energy density, high fiber content, and low glycemic index." So it's the concentration and accompaniments, rather that the sugar per se - a la jelly bean experiment mentioned above? Fruit juices, sports drinks, Coca-Cola and milk all have about the same amount of sugar - google it. Are they equally culpable? Milk has a different disaccharide, lactose, a glucose-galactose combination. Sucrose, table sugar, is the glucose-fructose disaccharide. Fruits and high fructose corn syrup (HFCS) have various combinations of glucose and fructose. Are all sugars bad? It's hard to malign milk. It was part of the paleolithic diet although not other animals' milk and way past infancy. The party line is that breast feeding can prevent obesity, but that's a myth. (31) One way that milk is like Coca-Cola is it's ability to cause dental caries. Milk bottle caries is a well described syndrome of rampant tooth decay caused by putting babies to bed with milk bottles. That causes prolonged exposure to milk in the mouth and bad teeth. I'm a tax-and-spend Democrat. I believe that government intervention to protect us is warrented for the salt and trans-fatty acid content of foods which is hidden and detrimental. State intervention is much more likely to be of benefit in those cases. In the case of sugar sweetened beverages government interventions will not be particularly beneficial to the obesity epidemic and can be dangerous if we think they should make a big difference. Then we are back to blaming the vicitms. 1. Dennison BA, Rockwell HL, Baker SL. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics 1997;99:15-22. 2. Smith MM, Lifshitz F. Excess fruit juice consumption as a contributing factor in nonorganic failure to thrive. Pediatrics 1994;93:438-43. 3. Dennison BA, et al. Children's growth parameters vary by type of fruit juice consumed. J Am Coll Nutr 1999;18:346-52 4. Alexy U, et al. Fruit juice consumption and the prevalence of obesity and short stature in german preschool children: results of the DONALD Study. Dortmund Nutritional and Anthropometrical Longitudinally Designed.J Pediatr Gastroenterol Nutr. 1999 Sep;29(3):343-9. 5. Skinner JD, Carruth BR. A longitudinal study of children's juice intake and growth: the juice controversy revisited. J Am Diet Assoc. 2001 Apr;101(4):432-7. 6. Malik VS, Shultze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr 2006;84(2):274-88. 7. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: A systematic review and meta-analysis Am J Public Hwealth 2007;97:667-75. doi:10.2105/ALPH.2005.083782 8. DiMeglio DP, Mattes RD. Liquid vs solid corbohydrate: effects on food intake and body weight. In J Obes relat Metab Disord. 2000;24:794-800. 9. Qi Q. et al. Sugar-sweetened beverages and genetic risk of obesity. N Engl J Med 2012;367:1387-96 10. de Ruyter JC et al. A trial of sugar-free or sugar-sweetened beverages and body weight in children. N Engl J Med 2012;367:1397-406. 11. Ebbeling CB et al. A randomized trial of sugar-sweetened beverages and adolescent body weight. N Engl J Med 2012;367:1407-16. 12. Cohen DA, Babey SH. Candy at the cash register - A risk factor for obesity and chronic disease. N Engl J Med 2012;367:1381-3 13. Pomeranz JL. Brownwell KD. Portion sizes and beyond - Government's legal authority to regulate food-industry practices. N Engl J Med 2012;367:1383-5. 14. Caprio S. Calories from soft drinks - do they matter? N Engl J Med 2012;367:1462-3. 15. Farley T. Support regulation of sugar-sweetened beverages. N Engl J Med 2012;367:1464-5. 16. Just DR, Wansink B. Do not support regulation of sugar-sweetened beverages. N Engl J Med 2012;367:1465-6. 17. Hu FB. Obesity Epidemiology 2008 by Oxford University Press. pp283-85,292-3 18. Brownell KD, Frieden TR. Ounces of prevention - The public policy case for taxes on sugared beverages. N Engl J Med 2009;360:1805-8. 19. Ludwig DS, Peterson KE, Gortmaker SL. Relation between consuption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001;357:505-08. 20. Wang YC et al. A penny-per-oz tax on SSB would cut health and cost burdens of diabetes. Health Aff Jan 2012 31:199-207. doi:10.1377/hlthaff.2011.0410. and quoted in AMANEWS July 23, 2012. 21. Forshee RA, Anderson PA, Storey ML. Sugar-sweetened beverages and body mas index in children and adolescents: a meta-analysis Am j Clin Nutr 2008;87:1662-71. 22. Ludwig DS Artificially sweetened beverages. Cause for concern. JAMA 2009;302(22):2477-8. 23. Tate DF et al. Replacing caloric beverages with water or diet beverages for weight loss in adults: main results of the Choose Healthy Options Consciously Everyday (CHOICE) randomized clinical trial. Am J Clin Nutr 2012;95:555-63. 24. Murtagh L, Ludwig DS. State intervention in life-threatening childhood obesity JAMA 2011;306:206-7. 25. Varness T, Allen DB Carrel A, Fost N. Childhood obesity and medical neglect. Pediatrics 2009;123:399-406. 26. ASBP News Sept/Oct 2011. 27. Letters to the editor. JAMA 2011; 306:1762-4. 28. Ludwig DS, Ebbeling CB, Livingston EH. Surgical vs lifestyle treatment for type 2 diabetes. JAMA 2010;308:981-2. 29. Mingrone G et al. Bariatric surgery vs conventional medical therapy for type 2 diabets. N Engl J Med. 2012;366:1577-85. 30. Shah M et al. Review:long-term impact of bariatric surgery on body weight, comorbidities, and nutritional status. J Clin Endocrinol Metab. 2006;91(11):4223-4231. 31. Cassaza K et al. Myths, presumptions and facts about obesity. N Engl j Med 2013;368:446-54.