California might be the first state to mandate “warning labels” on some sugar-sweetened beverages. SB 1000 would require some sugar sweetened beverages that containing more than 75 calories per 12 ounce serving to carry a warning label that says “Drinking beverages with added sugar(s) contributes to obesity, diabetes and tooth decay.” The legislation is widely supported by those who are concerned about the obesity epidemic. However, while many proponents have an academic understanding of the relationship between overeating, weight gain and diabetes, few seem to have little direct experience in counseling those who are struggling with expanding waistlines.

The causes of obesity and diabetes are multifactorial and more complicated than simply drinking soda. People may become overweight because they eat for comfort, coping or emotional reasons; others may have a genetic or hormonal issue. Most are not physically active. The problem with warning labels is that they enforce the assumption that all obesity is caused by overeating. This is not true. Having directly counseled obese adults and children from all socio-economic classes, it is clear that obesity is caused by numerous factors. Each individual’s struggle with weight gain is a personal journey. Effective behavioral change and weight management involves more than a warning label.

Soda warning label advocates claim that consumers have a right to know about the health problems related to sodas and other sugary drinks. From clinical experience, we know that obese people are not ignorant; many are aware that certain foods contribute to overweight and even diabetes. Labels characterize obese persons as mindless gluttons who are unaware of the nutritional value of certain foods. Moreover, warning labels may encourage others to make value or moral judgments about what and how someone eats.

Many overweight and obese persons are already targets of discrimination. Consider a recent UK proposal to show “pictures of fat people” on junk food (Parry) or a 2008 Mississippi proposal to ban “fat people” from restaurants or a clothing company who didn’t want plus size people wearing its clothes. Warning labels may further encourage “fat bullying” and cause people to make moral judgments about what and how someone eats. Many of my adult obese clients have been publically shamed and chastised by misinformed food police who point out the “sins” of eating or drinking certain foods or beverages.

Overweight and obese children are not immune to discrimination either and warning labels are unlikely to change behavior or curb childhood obesity. Overweight and obese children, like adults, may have a genetic predisposition to obesity; a disease that causes weight gain; and oftentimes issues with emotional overeating patterns (Butor PM) or lack of physical activity. In fact, a recent study of 42,316 Americans (Welsh et al NHANES 1999-2008) showed that consumption of added sugars and sugar-sweetened sodas has declined particularly in children. Now kids are swapping soda for coffee beverages (Branum et al). Interestingly, barista-made coffee beverages loaded with shots of sugary syrups and caffeine are unlikely be emblazoned with the “warning label.”

Instant Diabetes: Just add soda?

Blaming soda for the obesity epidemic is short sided and misguided but such opinions are not widely regarded by the popular press. Critics of the soda warning label legislation have been characterized as child hating, big industry zealots who are misinformed of the scientific facts. Nothing could be further from the truth. Many of us are scientists and clinicians that have worked with, listened to and counseled obese persons. We also know that legislation sold to the public on the basis of mistruths such as “Sugar in liquid form is ingested much faster than sugar in solid food, overloading the liver and pancreas, making it a direct cause of diabetes,” (San Jose Mercury News) harm the scientific integrity of any argument and insults the intelligence of anyone with common sense…consider that an estimated 99% of Americans have consumed a sugary beverage… are all 99% diabetic? The development of diabetes takes time and is strongly associated with genetics. Chances are you know people who routinely consume regular soda and are not obese, diabetic or in ill health.

So if soda warning labels won’t work to fight the obesity epidemic, what will? Easy solutions are elusive, but from a practical and educational perspective: Bring back home economic classes; start an elementary school garden and educate children about portion sizes; get parents involved in nutrition education and work with those from lower socioeconomic groups on strategies that incorporate healthier foods and extend their food budgets; revamp the SNAP program to provide vouchers for specific foods (like the WIC program) and provide nutrition education to recipients (Ly); commit public funds to facilitate lasting habit change—similar to smoking cessation classes. Many of these strategies have been successful, but dependent on implementation of tailored programs and individual commitment to change.

Real behavior change begins with addressing the root cause of the poor dietary habits and empowering people to make individual changes that work for them, not coercing through fear or shame. This means focusing on education programs that provide tools for effective habit change instead of investing in another ineffective government mandate that treats everyone the same.

“In the long run, we shape our lives, and we shape ourselves. The process never ends until we die. And the choices we make are ultimately our own responsibility.”

― Eleanor Roosevelt


What about “liquid sugar?”

The truth is “liquid sugar” from breast milk, baby formula, juice, soda, maple syrup, honey, sucrose (table sugar) dissolved in iced tea, lemonade, chocolate or flavored milks, the popular flavored syrups added to coffee beverages and the enteral feeding formulas (liquid tube feeding) we give our critically ill Intensive Care Unit patients tend to be higher glycemic index foods that temporarily raise blood sugar. (Gapparov and Harvard Health Publications) In response, insulin levels increase and drive the glucose into the cell where it is used as energy, stored as glycogen (storage form of glucose) or converted to, and stored as fat (in the case of excess caloric intake). Over time, excess caloric intake can lead to weight gain and obesity which are associated with the development of diabetes. Current diabetics and pre diabetics need to limit their sugar intake to manage their diabetes, this includes all forms of carbohydrate. The brain and active muscles prefer to use glucose as an energy source. Physical activity is key to burning excess calories.

What about the effectiveness of warning labels?

Warnings appear on everything from video games to alcohol and cigarette labels, but do they actually change behaviors? Historically, warning labels on controlled substances like alcohol and tobacco increase consumer awareness but studies are mixed as to their impact on behaviors. A recent Australian study shows that alcohol warning labels are unlikely to change adolescent drinking behaviors ((Scholes-Baylog et al.). The ineffectiveness of warning labels on drinking behaviors was also reported in studies by Stockwell et al, Greenfield et al and Mackinnon et al. Warning labels do not address the reasons why certain food choices are made.

 What about the obesity problem and California?

Obesity is a nationwide problem. It is admirable that the state of California is trying to do something to stem the rise in obesity, especially among the youth, but warning labels are not the answer. A recent publication entitled “Education, diet and environmental factors influence sugar-sweetened beverage consumption among California children, teens and adults” (Keihmer et al) shows the impact of demographic and socioeconomic factors on sugar sweetened beverage consumption. The proposed warning label will have little impact on the attitudes and health behaviors described in this publication, yet the article has some excellent and practical suggestions on how to achieve healthier behaviors through nutrition education and community based organizations. Californians may be better served if funds were allocated toward education programs that target the at-risk populations with practical ideas that encourage food portion moderation, hunger management, physical activity and limitation not elimination of certain foods.

“Our greatest duty to our children is to love them first. Secondly, it is to teach them. Not to frighten, force, or intimidate our children into submission, but to effectively teach them so that they have the knowledge and tools to govern themselves.”

― Richelle E. Goodrich, Smile Anyway: Quotes, Verse, & Grumblings for Every Day of the Year

 Selected References:

 Butor PM. Some psychological viewpoints on obesity. SPPO Psychiatry, Stockholm, Sweden Kiess W, Marcus C, Wabitsch M (eds): Obesity in Childhood and Adolescence. Pediatr Adolesc Med. Basel, Karger, 2004, vol 9, pp 124-136

Branum AM et al. Trends in caffeine intake among US children and adolescents. Pediatrics epub ahead of print February 10, 2014.

Engs RC. Do warning labels on alcoholic beverages deter alcohol abuse? Commentary. J. School Health. 198 59:3.

Gapparov MM. Human milk carbohydrates and its role in infant nutrition.

Greenfield T et al. Long term effects of alcohol warning labels: finding from a comparison of the United States and Ontario Canada. Psychol Mark 1999. 16:261-82.

Harvard Health Publications. Glycemic index and glycemic load for 100+ foods.

Heiden A. UW alumna’s research could lead to obesity prevention. University of Wisconsin Madison. Department of Nutritional Sciences Digest Newsletter. Spring 2014. Page 2.

Keihner AJ et al. Education, diet, and environmental factors influence sugar-sweetened beverage consumption among California children, teens and adults. CA Dept of Public Health

Ly N. Oh SNAP, its important. University of Wisconsin Madison. Department of Nutritional Sciences Digest Newsletter. Spring 2014. Page 7.

Mankinnon DP et al. The alcohol warning and adolescents: 5 year effects. Am J Public Health. 1993; 12:10-18.

Pan A and Hu FB. Effects of carbohydrates on satiety: differences between liquid and solid food. Curr Opin Clin Nutr Metab Care. 2011. 14:385-90.

Parry L. ‘Put pictures of fat people on junk food to show the dangers’: experts say rising obesity levels pose greater health risk than smoking. UK Daily Mail. May 19, 2014.

San Jose Mercury News. Editorial. May 29, 2014.

Scholes Balog KE et al. Aust NZ J Public Health. 2012;38:524-9.

Stockwell TR. A review of research into the impacts of alcohol warning labels on attitudes and behaviors. British Columbia Canada, University of Victoria, Center for Addiction Research of BC. 2006

Welsh JA et al. Consumption of added sugars is decreasing in the United States. Am J Clin Nutr 2011. 94:726-34.

Wilkinson C and Room R. Warnings on alcohol containers and advertisements: international experience and evidence on effects. Drug and Alcohol Res. 2009. 28;436-35

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