Author + information
- Walter Mashman, MD, Deputy Editor, JACC: Cardiovascular Interventions⁎ ()
- ↵⁎Address correspondence to:
Walter Mashman, MD, Deputy Editor, JACC: Cardiovascular Interventions, Piedmont Heart Institute, 275 Collier Road, Suite 300, Atlanta, Georgia 30309
The number one source of calories in the U.S. is soft drinks. Americans are obese and the excessive consumption of refined sugar is a major public health threat whose impact cannot be fully defined. The consumption of sugary soft drinks has been clearly linked to obesity in both children and adults. In addition to the obvious increased risk of diabetes and heart disease, there are other consequences of excessive soft drink consumption and national obesity including other medical problems and increased national economic strain. It is estimated that the annual cost of treating illness related to obesity in the U.S. is $147 billion (1), and that obesity accounts for 5% to 15% of deaths each year (2). We should support federal taxation of high calorie soft drinks and these revenues should be directed toward health care, perhaps in the form of funding for nutritional education and programs to encourage physical fitness. Interventional cardiologists should consider these issues as we move toward a national debate on the topic.
I love the taste of Coca-Cola and am pleased to indulge occasionally (I am drinking one now as I write this). According to the Coca-Cola Company, in 2008 1.6 billion servings were consumed per day. Therefore, on average, 25% of the world's population has a Coke every day. Coincidentally, according to the World Health Organization (WHO), in 2005 1.6 billion adults were overweight (3). If we assume a serving of Coke is 12 oz, it has 140 calories, which suggests that globally 224 billion calories are consumed daily. There are 3,500 calories in 1 lb of fat, so this would equate to 32,000 tons of fat per day. Let's say 37% of the global market is consumed in the U.S., and that diet sodas (assume no calories) account for 29% of the carbonated soft drink sales. We could then estimate that 16.8 million lbs of American fat are cultivated each day, and 6.1 billion lbs of American fat per year. That is about 20 lbs of fat per American per year; and that is just Coke. Then there is Pepsi, and whoever else. I concede that these calculations are very crude and somewhat flawed, but even if not completely accurate, they do roughly demonstrate the —ahem—gravity of the issue.
I recently had 3 patients who stand out in my mind. A young obese man was referred to me to evaluate his severe palpitations. He had no pathology aside from obesity, but drank 2 6-packs of Mountain Dew every day (2,040 calories and 660 mg of caffeine). A woman in her 20s was asked to see me to evaluate her exertional dyspnea. Again, aside from obesity, no pathology was found. I began the discussion about physical deconditioning and the need for weight loss, diet, and exercise. She abruptly put up her hand and emphatically said, “I cannot exercise.” I was curious and wondered what important condition I had missed in my detailed examination. I asked why she could not exercise and was stunned by her response: “I get all sweaty.” Excuse me? This week an obese young woman just diagnosed with diabetes and planning gastric bypass surgery told me that she drinks 8 cans of Pepsi per day. She is now considering cutting back. Knock-knock. Hello?
This is an American problem. It has been projected that by 2020 nearly one-half of the U.S. adult population will meet the WHO criteria for obesity (2). The U.S. ranks first by far in absolute soft drink consumption. In 1999, with <5% of the world's population, the U.S. accounted for one-third of total consumption. The average person in the U.S. drinks 3,296 oz of Coke per year, compared to 680 oz globally. Only Chile and Mexico drink more Coke products per capita. American children and teenagers consume about 2 cans of soda or “fruit drink” a day, and one-quarter of all teens drink as many as 4 cans a day, each containing about 150 calories. The Coca-Cola Company has nearly complete market penetration in the U.S., which means that essentially every American household purchases a Coke product.
There have been proposals and ongoing debates about federal taxation for the use of high-sugar and “energy” beverages. Most states already have a small tax. Points in favor of taxation include that this issue is a major public health problem whose burden is borne by all citizens, that marketing tactics may have potentially victimized some segments of the population, and that the excessive use of refined sugar is analogous to cigarettes and alcohol—both of which are federally taxed. I can think of only 2 legitimate arguments against taxation. One relates to civil liberties. Although this troubles me somewhat, I remain stubbornly firm in my position. The proposal is not to ban soft drinks, just to tax them. The other argument raises the “where do we draw the line?” question. I am also not swayed by this concern. We can debate this as we go. The current topic is soft drinks and these are the only “foods” whose consumption has been demonstrated to correlate with obesity. To help decide whether taxation is a good idea, one might consider in the current balance who wins and who loses. As discussed, our public health is currently compromised and ultimately all citizens pay (directly or indirectly) the financial and other costs of our health problems. The only winner in the current design is the soft drink industry who has reaped gigantic financial rewards. In 2000, Coca-Cola generated $48 billion in revenue, and in 2008 paid $3.5 billion to shareholders.
I believe strongly in individual rights (you have to trust me on this one), and I do agree with the concept of individual responsibility. No one made me drink that Coke I just had. Not my wife, not my mama, not the tooth fairy, and certainly not the Coca-Cola Company. I get to choose every bit of liquid that passes my gums. This is my responsibility. I also think, however, that there has to be some level of cultural responsibility. As physicians we should advocate on behalf of those who cannot, and as importantly advocate for the health of our population as a whole. Public health education will not improve this escalating problem without taxation to discourage consumption. The U.S. currently enjoys the lowest rate of tobacco use (19.8% of adults) in the world due to education and the taxation of cigarettes (4). The public health benefit of decreasing tobacco use in the U.S., however, is far overshadowed by the worsening obesity trends, with a net effect of reduction in the quality-adjusted life expectancy of 0.91 years (2).
Coca-Cola is a terrific company that has done great things. I trained at Emory University which has benefited substantially from the generosity of the Coca-Cola Company. I have always been grateful for that support. I live in the company's hometown where there is ubiquitous evidence of their aggressive support of the arts and Atlanta's cultural community. Coca-Cola is the ultimate icon of successful American capitalism. The soft drink industry is smart, wealthy, and powerful. It would seem that they are well positioned to diversify, evolve, and continue to thrive as new pressures are put in place.
Why should interventional cardiologists care about these issues? Cardiologists tend to be physically fit, nonobese, and probably drink fewer soft drinks than average. Those 20 lbs of fat per year are not carried by cardiologists. Public health aside, obesity is annoying for us. It increases the risk of all of the procedures we do, is associated with other comorbidities, worsens outcomes, and often provides extra technical challenges. Imaging is often suboptimal and in the operating room things are just more difficult. As our outcomes are increasingly scrutinized, we must continue to strive toward lowering complication rates. Obesity makes this difficult. The increasing prevalence of obesity should also push us in the U.S. more quickly toward the adoption of radial access for percutaneous procedures. Radial access has consistently been shown to be associated with lower complication rates, particularly in the obese population.
I am grateful that you have taken the time to read this. I feel refreshed. Ahhhhhhhh.
- American College of Cardiology Foundation
- World Health Organization