Nutritional Pearls: How Do Sugar-Sweetened Beverages Impact Your Health?

Mark is a 38-year-old male who drinks 2 to 3 diet soda beverages a day. He believes that since he is drinking a diet drink, he is not compromising his health.  

He presents with prediabetes so you ask him to cut down his sugar intake. He wants to know whether he can continue drinking his diet soda.

How would you advise him?

What is the correct answer?
(Answer and discussion on next page)

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Answer: Sugar-sweetened beverages contribute to weight gain, high blood pressure, poor cholesterol, and several comorbidities.

Recent research has focused on the effects of drinking sugar-sweetened beverages on our patients’ weight,¹ blood pressure, cholesterol scores, and comorbidities, such as diabetes, gout, and kidney disease.

There have been a number of different suggested approaches to gauge how the amount of sugary drinks impact consumers; these include limiting the size of beverages people can purchase (New York) to taxing the sugar content of the beverage (recently proposed in San Francisco).
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Diabetes Risk: Sugar-Sweetened vs Artificially Sweetened Beverages
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The Research

A group of researchers at the University of Alabama theorized that showing people concrete representations of the amount of sugar in a drink might deter people from drinking it. They devised a series of 4 interconnected studies to find out if that might not be the case.³

Study 1:

The researchers observed that the sugar content of a beverage is noted in each beverage’s nutrition facts in grams per serving. In their first study, they set up a table in a university common area and invited passersby to participate in their estimation study. Each person was shown a 20-ounce bottle of Pepsi and informed that the bottle contained 69 gm of sugar. They were then asked to move 69 gm of sugar from a 2-pound bag of sugar into a smaller container.

Half of the participants were given no further information. The other half was told that 2.5 gms of sugar was the size of a sugar cube to help them visualize the amount. On average, those without the extra information misestimated the volume of sugar by 50 gms, while those with the extra information only misestimated by an average of 9 gms.   

As a result, the researchers concluded that most people are not able to accurately visualize the amount of sugar represented by the number in the nutrition facts.

Study 2:

In their second study, the researchers surveyed 74 people anonymously. First the participants were asked how often they usually drank 4 different sugar-sweetened beverages: Coke, Sprite, Mountain Dew, and Dr. Pepper. (Note: Individuals who did not drink sugar-sweetened beverages were excluded from the study.) Then, for each of the 4 beverages, they were shown an image of the beverage and asked if the image made the beverage less (scale 1) or more (scale 5) attractive to drink. Each image of the beverages was randomly chosen from the following: the beverage without any special labels, the beverage plus a label stating the amount of sugar it contained in grams, or a pyramid of sugar cubes in an amount corresponding to the amount of sugar the beverage contained.

After. the participants were asked how often they intended to drink the 4 different sugar-sweetened beverages. Individuals reported being less likely to want to drink the sugar-sweetened beverages when the amount of sugar was presented in writing and far less likely to want to drink the beverage when the amount of sugar was presented in terms of sugar cubes.

Study 3:

In a natural corollary to experiment 2, over 100 passing college students were offered a free beverage for completing a survey. Several different sugar-sweetened and unsweetened beverages, including water, were displayed on 2 tables. On the first table, each sugar-sweetened beverage was displayed next to a pyramid of sugar cubes to illustrate the amount of sugar in each beverage. On the other table, a prominent label specified the number of grams of sugar contained in each beverage.

Half the students were directed to select their beverage from the first table and half from the other table. The result: Those who were directed to the table with the numeric labels (not the sugar cubes) were almost 3 times more likely to choose a sugar-sweetened beverage for themselves than those whose beverage was illustrated with a pyramid of sugar cubes.

Study 4:

In the fourth and final experiment, the researchers asked over 100 undergraduates to participate in a “learning by estimation” study. They were asked to estimate various amounts by converting 1 unit of measure into another—including currency, weight, volume, and distance.

For half of these participants, questions were included on converting grams of sugar into the approximate number of sugar cubes (~5 grams of sugar = 2 sugar cubes).

At the close of the experiment, the participants were asked to choose a reward. The reward options were presented in a list that included several sugar-sweetened beverages, labeled with the amount of sugar they contained, as well as water. Before choosing their reward, however, half of the participants were given a health message that excess sugar consumption was associated with obesity, type 2 diabetes, and heart disease.

The result: Individuals who had both learned how to convert grams of sugar into sugar cubes and were shown a health message about sugar were 30% less likely to choose a sugar-sweetened beverage for their reward than those who had not learned to convert grams into cubes.

What’s the “Take Home”?

The researchers felt that it was clear that people were not very good at estimating the physical amount of sugar in a beverage, but that when shown the amounts in concrete ways (the sugar cube pyramid) they would find the beverages less attractive. However, with some education people could be taught to visualize the amount of sugar in a beverage (converting grams to cubes) and that might be effective as well.

Tell your patients to take a moment to really think about how much sugar is in that can or bottle before they next choose a sugary beverage. Here is a slideshow to visualize sugar content.

References:

1. Harlan T. Drinking sugary beverages makes you gain weight. Dr Gourmet website. www.drgourmet.com/bites/2013/100913.shtml. Accessed October 14, 2014.
2. Harlan T. Sugary beverages and your health. Dr Gourmet website. www.drgourmet.com/bites/2010/110310.shtml. Accessed October 14, 2014.
3. Adams JM, Hart W, Gilmer L, et al. Concrete images of the sugar content in sugar-sweetened beverages reduces attraction to and selection of these beverages. Appetite. 2014;83:10-18.