Is Soda the New Tobacco? An Expert, and New CDC Data, Say Yes

The way sugar-sweetened beverages have been mar­keted—so that get children hooked early, despite long-term health effects—is strikingly similar to how tobacco companies peddled cigarettes, both before and after the 1964 US Surgeon General’s report highlighting the link be­tween smoking and cancer.¹

So argues Marion Nestle, PhD, MPH, in Soda Politics, a book that traces the history of how soda giants Coca-Cola and Pep­siCo came to occupy their place in both our consciousness and our refrigerators. While US consumption of sugary drinks, especially soda, declined 25% between 1998 and 2014, that drop has been uneven in a way that also resembles tobacco: more sugary drinks are consumed in poorer states that are now plagued with higher rates of diabetes and obesity.

In her introduction, Nestle, the Paulette Goddard Professor of Nutrition, Food Studies, and Public Health at New York Uni­versity, describes the revelation she experienced at a confer­ence during the 1990s. Already very interested in the effect of sodas on health, she attended a talk on cigarette advertising to global markets, much of it aimed at children. “The speakers demonstrated how cigarette companies deliberately created their ads to blend into the surroundings and slip below the radar of conscious notice or critical thought,” she writes. “I left that meeting convinced that those of us who care about diet and health ought to follow the lead of anti-smoking advocates and pay that same kind of close critical attention to the mar­keting of Coke and Pepsi.”¹

In gathering information for Soda Politics, one of Nestle’s biggest challenges was obtaining data on how much soda is produced and consumed. For decades until 2003, the US De­partment of Agriculture (USDA) published data on the number of gallons of carbonated beverages produced by the industry, until the companies refused to allow publication. Nestle paid to gain access to the industry data, which show production leveling off and declining after 2003.

“The word is out that they’re not good for you,” Nestle said of soda and sugary drinks in an interview with Evidence-Based Diabetes Management (EBDM). There’s been a real shift in con­sumption patterns, she said, but that doesn’t mean the bever­age industry is giving up without a fight.

GETTING SODA OUT OF SNAP

Nestle is among the nutrition advocates who argue that tack­ling America’s obesity and diabetes crisis means taking on the soda industry through a variety of means, from taxes to warn­ing labels, and especially getting soda removed from eligibility for the Supplemental Nutrition Assistance Program (SNAP), better known as food stamps. The logic is the same as new laws that are banning smoking from public housing: taxpay­ers should not subsidize unhealthy behavior, the consequenc­es of which drive up Medicaid and Medicare costs.

A 12-ounce can of Coke has 140 calories, 39 g of sugar, and no nutritional value. If the empty calories from soda are such an obvious cause of obesity, why does SNAP still pay for soda? Because, Nestle writes, the beverage companies have fought every attempt at reform. What sets her apart from many nutrition advocates is her ability to “follow the money” and show the connections between industry influence—peddling and health policy. (Her well-known blog, Food Politics, regu­larly calls out industry-funded nutrition studies that produce favorable results.)

For example, when New York City sought a waiver from USDA in 2011 to keep soda out of SNAP, she writes, the Ameri­can Beverage Association (ABA) called it “another attempt by government to tell New Yorkers what they should eat and drink.” ABA also targeted members of the Congressional Black Caucus (CBC) and urged them to get USDA to reject the waiver. Coke and Pepsi each also contributed to the CBC Foundation, in the range of $250,000.¹ (Right now, a New York State law­maker is trying to get soda out of SNAP through legislation.²)

The CBC contribution is a classic example of soda market­ing that Nestle highlights: gifts to charitable causes, especially in minority communities, that build goodwill for soda compa­nies. The soda giants are masters at seizing such moments: in January, Coke and Pepsi (along with Walmart) announced plans to distribute free water to public school children in Flint, Michigan, where lead contamination has made the public wa­ter system a health hazard.³

Nestle is not alone in taking aim at the soda giants. The Center for Science in the Public Interest (CSPI) has increasing­ly set its sights on Big Soda, calling for soda taxes and warn­ing labels in order to get sugary drinks out of kids’ menus, hospital settings, and government facilities.4 As EBDM went to press, CSPI cited new data from CDC, which bolster Nestle’s case that marketing of soda hits hardest on the poor and on minorities, with serious health consequences.^4,5

And the soda companies, looking to replace lost revenue, have taken one more page from the cigarette manufacturers, Nestle writes: they have looked overseas for new customers, bringing soda to the developing world.

DATA SHOW LINKS WITH DIABETES AND OBESITY

A review of the CDC study, which covered 23 states and the District of Columbia in 2013, identified the share of the popu­lation that reported drinking at least 1 sugar-sweetened bever­age per day, which could include a nondiet soda, a sweetened iced tea, a sugar-sweetened fruit drink, or a sports energy drink. States with the highest sugary drink consumption were Mississippi (47.5%), Louisiana (45.5%), and West Virginia, (45.2%).⁵ According to 2013 data from CDC, these states rank second, seventh, and fourth, respectively, among the 50 states for incidence of diabetes per 100 population (see TABLE).⁶

These states also had 3 of the 4 highest self-reported rates of obesity in the country in 2014, according to the Behavioral Risk Factor Survey System. After Arkansas’ rate of 35.9%, West Virginia reported 35.7%, followed by Mississippi at 35.5% and Louisiana at 34.9%.⁷ The CDC study also found that sugary drink consumption was most common among the 18-to-24- year-old age group (43.3%), non-Hispanic blacks (39.9%), the unemployed (34.4%), and those with less than a high school education (42.4%).⁵ CSPI called for action because the study found soda consumption is 1.5 times higher among blacks and 1.4 times higher among Hispanics than whites.⁴

RESEARCH, MARKETING, AND MONEY

Much like the tobacco companies before them, Nestle writes, the soda industry and its ally, the sugar industry, have flexed their muscles to open new markets in the developing world, removing any obstacles—including individuals who ques­tioned the health effects of soda.

Nestle chronicles the saga of Derek Yach, MBChB, MPH, for­merly of the World Health Organization (WHO). In 2006, he was working on the WHO strategy to extend worldwide the US recommended limits that no more than 10% of daily calories come from sugar. With no warning, Yach was pushed out of his research post. Leaked e-mails later revealed the role that US lobbyists played in getting senators from sugar- and corn syrup—producing states to threaten to cut WHO funding. The report Yach was working on lacked the 10% recommendation, but a report issued in 2015 did call for this limit.⁸

Yach then stunned former colleagues when he accepted a post with PepsiCo to run its global health strategy, to try to change the industry from within. In a response that Nestle published, Yach wrote that distrust of the industry is so mas­sive that he was blackballed from publishing in many aca­demic journals. He reported working with PepsiCo to reduce salt, sugar, and saturated fat in its food products, as well as re­formulation strategies for many foods and beverages. He has since left PepsiCo to run the Vitality Institute.

Coca-Cola, meanwhile, copied the tobacco companies of the 1960s by funding research to deflect blame for soda’s role in obesity. In her book, Nestle writes about this “physical activity diversion,” and just after Soda Politics went to press, Coca-Cola’s efforts massively backfired. In August 2015, The New York Times wrote the first of several stories that would expose that Coca- Cola had more than a funding role in the Global Energy Balance Network (GEBN), whose scholars found that lack of exercise, not calorie consumption, is responsible for obesity.⁹ The Uni­versity of Colorado returned a $1-million grant that had origi­nated with Coca-Cola, and the network has since disbanded.¹⁰

To Nestle, the GEBN saga was shocking on one level, but not when taken in the context of where things had been headed. Previously, research backed by Coca-Cola had attacked the va­lidity of the National Health and Nutrition Examination Survey (NHANES) data, which ask Americans about what they eat and drink to track consumption and public health trends. As Nes­tle writes, NHANES data, which have consistently found that about half of Americans drink soda on any given day, also find that about 20% drink more than 4 sodas a day and consump­tion begins when children are very young.

The media’s ability to document how Coca-Cola was direct­ing a research enterprise “was the smoking gun,” Nestle said in the EBDM interview. “And the fallout has been extraordinary.”

DOCUMENTING GLOBAL MARKETING

Nestle’s Soda Politics is a road map through the paths that bev­erage companies have plowed into the fabric of American life through marketing, charitable gifts, and, increasingly, targeted outreach to minority groups, especially the growing Hispanic population. Despite this, public health leaders have succeed­ed in pushing back against Big Soda: a massive change came in 2013 when McDonald’s stopped offering soda as the default option with Happy Meals. After 2 years, the share of children ordering soda dropped from 56% to 48%.¹¹

Since the Yach incident, advocacy groups are singling out WHO to do more to lead efforts against soda consumption. In February, CSPI issued a report, Carbonating the World, that documents levels of global investment by the soda compa­nies as US consumption has ebbed.¹² The group found that Coca-Cola has invested $12.4 million in Mexico, which leads the world in obesity; other investments include $7.6 billion in Brazil, $17 billion on the African continent, $4 billion in China, $5 billion in India, and $1.2 billion in the Philippines.¹²

Both Soda Politics and the CSPI report discuss at length mar­keting efforts that reach children, and neither is swayed by in­dustry’s claims of improved behavior. Nestle spends an entire chapter picking apart the guidelines that bar “direct” advertis­ing when 35% of the audience is under age 12. Like Nestle, the CSPI authors draw multiple comparisons to earlier efforts by Big Tobacco to take their strategies abroad once US sales declined.^1,12

In response to the CSPI report, the International Council of Beverage Associations (ICBA) called beverage companies “good global citizens” and said the report “ignores the eco­nomic importance of jobs and the investments beverage com­panies bring to the hundreds of thousands of employees and their families.” ICBA took particular exception to the claims about marketing to children, saying that tests show 94% com­pliance with the advertising guidelines in every market.¹³

Nestle is encouraged by the advocacy work she sees, but said more needs to be done. “There is interest in tax initiatives in a lot more locations,” she said, and more papers about to be published, but the long road of public education remains. It’s a matter of getting children to drink water, getting the FDA to put “added sugar” on food labels, and promoting a simple message: “We shouldn’t be drinking sugar.”

REFERENCES

1. Nestle M. Soda Politics: Taking on Big Soda (and Winning). 1st ed. New York, NY: Oxford University Press; 2015.

2. Olson S. SNAP benefits may cut out junk food and luxury items in effort to limit food stamps to ‘essentials.’ Medical Daily website. http://www.medicaldaily.com/food-stamps-junk-food-snap-benefits-luxury-items-374786. Published February 23, 2016. Accessed February 28, 2016.

3. Walmart, Coca-Cola, Nestle, and PepsiCo come together to provide Flint, Mich., public schools with water for students through the end of the year [press release]. Bentonville, AR: Walmart; January 26, 2016. http://news.walmart.com/news-archive/2016/01/26/walmart-coca-cola-nestle-and-pepsico-come-together-to-provide-flint-mich-public-schools-with-water-for-students-through-the-end-of-the-year. Accessed February 28, 2016.

4. Americans guzzling too much soda, despite declines [press release]. Washington, DC: Center for Science in the Public Interest; February 25, 2016. http://www.cspinet.org/ new/201602251.html. Accessed February 25, 2016.

5. Park S, Xu F, Town M, Blanck HM. Prevalence of sugar-sweetened beverage intake among adults—23 states and the District of Columbia, 2013. Mortal Morb Wkly Rep. 2016;65(7):169- 174. doi: 10.15585/mmwr.mm6507a1.

6. National Diabetes Surveillance System. CDC website. http://gis.cdc.gov/grasp/diabetes/ DiabetesAtlas.html. Accessed February 25, 2016.

7. Adult obesity facts. CDC website. http://www.cdc.gov/obesity/data/table-adults.html. Updated September 21, 2015. Accessed February 25, 2016.

8. WHO calls on countries to reduce sugars intake among adults and children [press release]. Geneva, Switzerland: World Health Organization; March 4, 2015. http://www.who.int/media­centre/news/releases/2015/sugar-guideline/en/. February 28, 2016.

9. O’Connor A. Coca-Cola funds scientists who shift blame for obesity away from bad diets. The New York Times website. http://well.blogs.nytimes.com/2015/08/09/coca-cola-funds-scientists-who-shift-blame-for-obesity-away-from-bad-diets/?_r=0. Published August 9, 2015. Accessed February 25, 2016.

10. O’Connor A. Research group funded by Coca-Cola to disband. The New York Times website. http://well.blogs.nytimes.com/2015/12/01/research-group-funded-by-coca-cola-to-disband/. Published December 1, 2015. Accessed February 25, 2016.

11. Giammona C. McDonalds finds many kids still want soda with Happy Meals. Bloomberg website. http://www.bloomberg.com/news/articles/2015-06-25/mcdonald-s-finds-many-kids-still-want-soda-with-happy-meals. Published June 25, 2015. Accessed February 25, 2016.

12. Taylor AL, Jacobson MF. Carbonating the world: the marketing and health impact of sugar drinks in low- and middle-income countries. Center for Science in the Public Interest website. http://www.cspinet.org/carbonatingreport.pdf. Accessed February 9, 2016.

13. Caffrey M. Soda giants turn to developing world to replace lost US sales, report finds. American Journal of Managed Care website. http://www.ajmc.com/focus-of-the-week/0216/ soda-giants-turn-to-developing-world-to-replace-lost-us-sales-report-finds. Published February 9, 2016. Accessed February 25, 2016.

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