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How Soft Drinks Are Harming Americans' Health
by Michael F. Jacobson, PhD.
Table of Contents:
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 (Figure 1) 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.
Figure 1:
Annual soft drink production in the U.S.
(12-ounce cans per person)
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). |
|||||||||||||||||||||||||
|
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| 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 2½ 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 2½ 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) |
||||||||||||||||||||||||||||||
|
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| 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 ¾ of a can per day, while the 95th-percentile
teen drank 2¼ 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 (Figure 2). In the 1950s, Coca-Cola's 6½-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.
Figure 2: Growing size of 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 1½ 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:
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:
- 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.
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 (Figure 3). 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 ¼ cups of fluid milk. Girls consumed about 1 ½ 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
|
|
| USDA: NFCS, CSFII |
(ounces per day).
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 1½ 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
|
||||||||||||||||||||||||||||||||||
| Prices at Washington-area 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
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.
- 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.
Endnotes
1. JAMA. 1942;120:763-5.
2. This review does not cover sweetened non-carbonated beverages (bottled
ice teas, fruit drinks and ades, bottled ice tea, etc.).
3. National Soft Drink Assoc. web site, http://www.nsda.org/.
4. Ibid.
5. USDA/ERS: Food Consumption, Prices, and Expenditures,
1970-95, Stat. Bull. No. 939 (August, 1997).
6. Unless otherwise specified, all data on consumption of soft drinks,
milk, and calorie intake were obtained or calculated from U.S. Department
of Agriculture (USDA) surveys (one-day data) particularly Continuing
Survey of Food Intakes of Individuals (CSFII), 1994-96 (Data Tables
9.4, 9.7, 10.4, 10.7); 1987-88 (Report No. 87+1, Tables 1.2-1 and -2;
1.7-1 and -2); Nationwide Food Consumption Surveys, 1977-78 (Tables
A1.2-1 and -2; A1.7-1and -2). Intake of added sugars by age was obtained
from USDA's analysis for purposes of the Food Guide Pyramid (two-day
1996 data, Table 6). Teens' consumption of vegetables, fruit, and other
foods also is from Pyramid Servings Data, USDA, Dec. 1997, based on
CSFII, 1996. We are grateful to USDA staff members in the Food Surveys
Research Group for their assistance. (See USDA web site: www.barc.usda.gov/bhnrc/foodsurvey/home.htm)
7. Analyses by Environ, Inc., Sept. 1998, based on USDA CSFII 1994-96
two-day data.
8. Ibid.
9. CSPI survey, August 26, 1998.
10. Nutrition Action Healthletter. 1998 (July/Aug.);25(6):6.
11. Am. J. Clin. Nutr. 1995;62(suppl):178S-94S.
12. Those dietary surveys find that consumers report
consuming only 57% of all soft drinks produced. While some soft drinks
are wasted or returned to manufacturers, that fact provides good evidence
that the surveys greatly underestimate actual intake.
13. U.S. Dept. Agr. The Food Guide Pyramid.
Home and Garden Bulletin No. 252, Oct. 1996, p. 17.
14. USDA's recommendation applies to diets that include
30% of calories from fat. Because 33% of the calories teens consume
come from fat, there is even less room in the diet for added sugar.
15. J. Am. Diet Assoc. 1998;98:537-547.
16. USDA CSFII 1994-96.
17. Diet sodas, which provide no calories, constitute
only 4% of soft-drink consumption by teenage boys and 11% by teenage
girls.
18. Pediatrics. 1997;100:323-9. Pediatrics.
1998;101:952-3.
19. USDA, Center for Nutrition Policy and Promotion, CNPP-5; The Healthy
Eating Index, 1994-96, July 1998.
20. Personal communication, Lisa Harnack, Sept. 22, 1998.
21. J. Am. Diet. Assoc. 1986;86:493-9.
22. Analyses by Environ, Inc., see note 7. Calcium was
the only micronutrient examined.
23. National Soft Drink Assoc. "Soft Drinks and Nutrition." Washington,
D.C. (undated).
24. New York Times. May 26, 1998, p.D1.
25. Arch. Pediatr. Adolesc. Med. 1995; 149:1085-91.
Morbidity Mortality Weekly Report. March 7, 1997;46(9):199-201.
26. Troiano RP, et al. "Energy and fat intake of children
and adolescents in the United States. Data from the National Health
and Nutrition Examination Surveys." Am. J. Clin. Nutr. In press.
27. Analyses by Environ, see note 7.
28. "Embrace Your Health! Lose Weight if You Are Overweight" NHLBI
and Office of Research on Minority Health, NIH Publication No. 97-4061,
Sept. 1997.
29. National Osteoporosis Foundation. "Fast facts on
osteoporosis." Web site, www.nof.org/stats.html.
30. Institute of Medicine. Dietary Reference Intakes: Calcium,
Phosphorus, Magnesium, Vitamin D, and Fluoride. 1997; pp.4-28.
31. Analyses by Environ, see note 7.
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42. Ibid.
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44. American Psychiatric Association. Diagnostic
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51. Associated Press. "Consumer group attacks artificial
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52. Beverage World web site, http://www.beverageworld.com/.
53. Beverage Digest web site (data expressed in 1998 dollars).
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55. Wall Street Journal, May 8, 1997, p.1.
56. Wall Street Journal, Sept. 15, 1997, B1.
57. Selling to Kids, August 19, 1998, p. 4.
58. Chronicle of Philanthropy. July 30, 1998, p.25.
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60. Bureau of Labor Statistics, U.S. Department of Labor.
61. Coca-Cola Co. Annual Report, 1997; M. Douglas Ivester's
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62. Coca-Cola Co. Annual Report, 1997.
63. Arkansas Department of Finance and Administration,
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