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May 1, 2012

The Relationship between Obesity and Sugar Sweetened Beverages, Testimony from Dr. Bechara Choucair

Commissioner of the Chicago Department of Public Health

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Good morning.  I am Dr. Bechara Choucair, and I serve as the Commissioner of the Chicago Department of Public Health.  I want to thank Alderman Cardenas for calling this critical hearing to share information on the detrimental effects of sugary beverages, their relationship to obesity, and most importantly, potential strategies for decreasing the number of people affected by chronic diseases associated with obesity.

Our Healthy Chicago public health agenda, identified obesity as a top priority.  Our goal is to prevent and control overweight, obesity and related chronic disease, and we’ve identified three related targets for:

  • Reducing adult and childhood obesity, 
  • Increasing consumption of fruits and vegetables, and
  • Eliminating the number of Chicagoans living in low access food areas (also known as food deserts).

I noted this hearing as being critical because Chicago faces serious obesity challenges. Obesity is one of the top underlying preventable causes of death in the U.S., increasing the risks for the three leading causes of death - heart disease, cancer and stroke – and for other conditions, including diabetes, hypertension and osteoarthritis.  The impact of obesity on our children is staggering.  Children are now being diagnosed with high blood pressure and Type 2 diabetes, which until recently was seen primarily in older adults.   And obesity researchers anticipate this could be the first generation that will have a lower life expectancy than their parents.

We will need to pursue multi-pronged and bold initiatives to address this challenge and improve the health of all Chicagoans.   Strong systems, environmental changes, and sound policy are needed to support healthy behaviors.  To date, the City has taken several positive steps, including:

  • Creating more and safer park space where Chicagoans can be active,
  • Establishing Play Streets to increase neighborhood recreational opportunities,
  • Working to implement a Complete Streets Policy and Bike Sharing Program to encourage more walking and biking,
  • Implementing standards that ensure sufficient nutrition and physical activity for children in day care centers,
  • Attracting grocery stores to underserved neighborhoods so people can better access healthier foods,
  • And implementing healthy vending policies at the schools, parks, and coming soon, in City buildings.

While none of these initiatives will themselves eliminate our overweight and obesity problems, it is the collective effect of these and other actions that will make a difference.

Why a Focus on Sugary Drinks

With myriad ways to improve health and fight obesity, why are we so focused on sugar?   It’s because sugary drinks are the biggest source of added sugar in the U.S. diet, and consumption of these drinks in the U.S. has doubled over the last 30 years.[i]   Let me share with you how this has happened.

First there’s marketing.  In 2010, the beverage industry spent $948 million marketing their products on television, online, in schools, and throughout communities.[ii]   And nearly half of advertising spending (46%) was directed towards regular soda.

Of this nearly $1 billion investment, nearly $500 million is spent annually on marketing campaigns directed at children – more than the marketing budget for any other consumable product.[iii]

Portion sizes have also changed.  Since the 1950’s, sugar-sweetened beverage servings have dramatically increased in size so that the typical bottle size sold in stores today is 20 ounces; fast food restaurants increased their typical portion to 32 ounces (often including free refills); and convenience stores began selling 64-ounce “Big Gulps” often for less than the price of a 20-ounce bottle.  

A third contributor is pricing.  This graph uses Bureau of Labor Statistics to show the prices of different beverages and foods over the last three decades.  Relative to the price of everything else in the economy, sodas (the orange line on the bottom) are 33% cheaper than they were in 1978.  By contrast, vegetables (shown in purple) are 41% more expensive and fruits (the green line at the top) are 46 percent more expensive. So if in 1978, a bag of oranges cost the same as one big bottle of soda, today that bag costs the same as three big bottles of soda.

Finally, product availability has expanded dramatically as a wide array of sugary drinks are sold nearly everywhere – movie theaters, workplaces, fitness clubs, shopping malls, big box stores, and of course supermarkets and convenience stores.

I want to speak for just a moment about the amounts of sugar in sweetened drinks.  Depending upon the specific soft drink, a 12-ounce can of soda contains between 9 and 12 teaspoons of sugar, and 20-ounce bottles contain between 15 to 20 teaspoons of sugar.   Those who want that tempting 64-ounce cup may find themselves consuming between 54 and 63 teaspoons of sugar, shown in the glass.   I know of no parent that would knowingly hand their child the glass of sugar show here and allow them to ingest it in one sitting.

But this is not just about soda because other beverages contribute to the obesity problem as well.   A bottle of iced tea typically has  9 teaspoons of sugar , and the energy drinks our youth are gulping-down have 16 teaspoons of sugar. 

Now some might ask “what’s wrong with a little sugar every now and then?”  And the answer is nothing - if it’s a little and if it’s every now and then.    But the average American consumes 45 gallons of sugary drinks a year – enough to fill this garbage can.  This translates to 42 pounds of sugar annually – or about as much as a five year-old child weighs!

HEALTH IMPACTS

So what does all this sugar mean in terms of our health?   This slide shows how sugary dinks work to increase risks of obesity, diabetes and other chronic diseases.

Researchers have found that adults who drink one or more soda per day are 27% more likely to be overweight or obese.[iv]   The figures are even more disheartening for children, whose risk of obesity goes up by 60% with each additional soda.[v] 

In Chicago, our childhood obesity rates are more than twice the national average, and obesity among high school students increased by 20% between 1999 and 2009.  Over two-thirds (67%) of Chicago adults are either overweight or obese. 

In this slide we can see that the disparities we often see in chronic diseases exist when it comes to obesity.    A local study of six Chicago neighborhoods found significantly higher levels of obesity in predominantly African American and Latino communities, than in a white community, shown on the far right.[vi]

Diabetes is frequently linked to obesity.   According to the CDC’s National Diabetes Surveillance System, there were an estimated 278,900 adults diagnosed and living with diabetes in Cook County in 2004.  By 2009, this number had increased by 23% to 343,578.  

Individuals who drink one to two sugar-sweetened beverages per day have 27% higher risk for developing type 2 diabetes,[vii] and women who consume one or more servings of a sugar-sweetened beverage daily are twice as likely to develop type 2 diabetes.[viii]    Women who drink more than 2 sugar-sweetened beverages per day also face a 40% higher risk of heart disease.[ix] 

These conditions are just the tip of the iceberg.  Other health consequences of obesity include Coronary heart disease; cancers (endometrial, breast, and colon); hypertension (high blood pressure); stroke; liver and gallbladder disease; sleep apnea and respiratory problems; osteoarthritis, and gynecological problems, including infertility.

COSTS OF OBESITY

There are significant economic costs associated with the obesity epidemic.  The CDC estimates that $147 billion annually is spent on obesity related health care costs. These costs fall disproportionally on the public health care system, pulling resources from already strained public programs like Medicare and Medicaid.  Closer to home in Illinois, obesity in adults adds $3.4 billion to annual health care costs.[x]  

Obesity is also affecting private employers - who suffer an estimated $45 billion a year in medical expenditures and productivity losses.  Advocate Health Care, one of the largest health care providers in the Midwest, has estimated that 69% of their employees are overweight, and in 2009 reported nearly $6 million in lost productivity due to obesity in that year alone. That’s six times as much as the costs attributed to smoking. [xi]  At the individual level, persons who are obese have health care costs that average about 30 percent above those for their normal weight counterparts.[xii]

And there are other economic impacts on communities with high obesity rates.  Businesses may be reluctant to locate to areas where workplace pools are unhealthy.

So from both a health and financial perspective, we cannot afford to sit by and do nothing.  

So What Do We Do?

Earlier I noted that no single intervention by itself will be sufficient in combating the obesity epidemic.  However, there are steps that can be taken that we know will help in this fight.  We know that taxing at the right level can reduce consumption of sugary drinks, and that reducing consumption will help reduce the prevalence of obesity.[xiii]

 A growing body of evidence suggests that reducing consumption of sugary drinks could be the single most effective intervention in reducing the prevalence of obesity in the United States.   Earlier, I mentioned that the increased consumption of sugar-sweetened beverages was the result of bold marketing campaigns, increases in portion sizes, concerted efforts to keep prices low, and dramatic expansion of product availability.   So we need to address this problem with a similar approach.   

  • Public awareness is critical, and we are committed to getting the word out about the health-related effects of sugary drinks.  Since the public health community lacks the annual $900 million budget that the industry has for marketing campaigns, we must leverage our existing resources and partnerships to get the word out about the health effects of sugar consumption. 
  • Limiting access points is another way to reduce consumption of sugar sweetened beverages.  Within the next few months, the City of Chicago will join the Chicago Public Schools and Park District in implementing a healthy vending policy.  What this means is that employees of and visitors to City-owned and operated facilities will see greater options for healthy beverages and snacks.  Our goal is to make the healthy choice the easy choice.  
  • Pricing is another much-discussed strategy.  Policy makers have looked to the success of tobacco taxes in reducing smoking as a potential means to achieve the same reductions for sugary drink consumption. 

Leading health care economist Frank Chaloupka recently estimated the potential impact of a one cent per ounce tax on sugar-sweetened beverages on Illinois.[xiv]  Among his findings were a reduction in obesity of over 185,000 Illinoisans, including more than 45,000 children ages 2 through 17 years; and the prevention of nearly 3,500 cases of type 2 diabetes, with a reduction in diabetes health costs of nearly $21 million.[xv]  Overall, the study estimated reductions of nearly $151 million in obesity-related health care costs. 

As I mentioned earlier, there is no single strategy that by itself will sufficiently address the obesity epidemic.  It will take multiple efforts that impact systems, environments and policies.   But there is one approach that characterizes almost all of our public health work – and that is partnerships.   We collaborate frequently with other public health stakeholders, community partners, academia, and the faith and philanthropic communities, to name a few.  

I would like to briefly mention Pepsico, who, like us, has committed to the First Lady’s Let’s Move campaign, and that like us is working to reduce sugar in beverages and remove full calorie sweetened drinks from schools.   They are also working to reduce sodium in snack products and increase the availability of healthier options.

We do have an opportunity to work closer with the beverage industry.   No companies go into business with the intention of harming the public’s health.  In fact many do contribute to health improvement efforts. While we are always pleased to support efforts to increase park space and enhance physical opportunities for youth, we must also work with the beverage industry on formulating food policies, and other systems-focused efforts that will result in sustainable changes to support Chicagoans in their efforts to be healthy.  

In closing, I want to again applaud the Committee on Health and Environmental Protection for calling attention to one of our city’s leading health concerns – obesity – and for exploring sustainable policy approaches to address it.

_______________________________________________________________________________________________

[i] Popkin, BM.  Patterns of beverage use across the lifecycle. Physiology and Behavior. 2010 ; 100(1): 4-9.

[ii] The Prevention Institute.  http://preventioninstitute.org/action-center-sa/news-a-updates/802-new-qkick-the-canq-campaign-helps-make-the-case-against-soda.html

[iii] Sugar Water Gets a Facelift: What Marketing Does for Soda.  Berkeley Media Studies Group, Sept 2009

[iv] Babey SH, Jones M, Yu H, Goldstein H. Bubbling Over: Soda Consumption and Its Link to Obesity in California. UCLA Center for Health Policy Research and California Center for Public Health Advocacy, 2009.

[v] Ludwig DS, Peterson KE, Gortmaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis. Lancet 2001; 357: 505-08.

[vi] Source:  Improving Community Health Survey, Report I., Sinai Urban Health Institute: Chicago, IL.  http://www.suhichicago.org/files/publications/P.pdf

[vii]Metabolic Syndrome= clustering of metabolic risk factors that increase the risk for heart disease. Grundy SM et al. Definition of Metabolic Syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition. Circulation. 2004; 109: 433–438.

[viii] Schulze MB, et al. Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. Journal of the American Medical Association. 2004; 292:927–934.

[ix] Fung TT, Malik V, Rexrode KM, Manson JE, Willett WC, Hu FB. Sweetened beverage consumption and risk of coronary heart disease in women. American Journal  of Clinical Nutrition. 2009; 89: 1037–1042.

[x] Illinois Department of Public Health. Obesity prevention initiative: A report to the General Assembly. December 2010

[xi] Kaiser Health News. http://www.kaiserhealthnews.org/stories/2010/july/16/ft-obesity-workplace-costs.aspx. July 16, 2010

[xii] Yale Rudd Center for Food Policy and Obesity.  Economic impact of obesity.  http://www.yaleruddcenter.org/what_we_do.aspx?id=82

[xiii] Smith, TA, et. al.  Taxing caloric sweetened beverages: Potential effects on beverage consumption, calorie intake, and obesity. United States Department of Agriculture, Economic Research Services, Report Number 100. July 2010.

[xiv] Chaloupka, FJ, et.al.  Estimating the potential impact of sugar-sweetened and other beverage excise taxes in Illinois.  2011.

[xv] Ibid.