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LETTER TO THE EDITOR |
American Beverage Association
1101 16th Street, NW
Suite 700
Washington, DC 20036
E-mail: mstorey{at}ameribev.org
Dear Sir:
We appreciate the interest that Bes-Rastrollo and Martinez-Gonzalez have shown in our recent article in the Journal (1), and we welcome the opportunity to share our response. They mention 3 articles that were not included in our analysis. We did not mention these articles because they were published after our article was submitted for publication. Sichieri et al (2) found no statistically significant reduction in body mass index (P = 0.33) between the treatment and control groups, but they did find a statistically significant reduction in body mass index for the subgroup of females who were overweight at baseline. Libuda et al (3) also found no statistically significant association between soda consumption and measures of body mass index or body fat in most of their analyses. The only reported statistically significant association was for girls, and that relation was not significant at the 0.05 confidence level (0.055 SD score/MJ increase in regular soft drink consumption; P = 0.08) These results are entirely consistent with the findings from our meta-analysis. The third study did report a statistically significant association between the odds of being overweight and between-meal consumption of sugar-sweetened beverages (4); however, the study design was different from those included in our meta-analysis in that it examined only a subset of sugar-sweetened beverage consumption. On the basis of our sensitivity tests, we strongly doubt that the inclusion of these studies would make any substantive changes in our conclusions.
The authors also point out that the studies included in our meta-analysis may have methodologic problems, most importantly differential underreporting of sugar-sweetened beverage consumption. We agree that this is a limitation of the studies included in the meta-analysis, and we noted the possibility of systematic measurement error in our limitations section. However, the studies included in the meta-analysis used validated dietary instruments, and they are widely cited in the scientific and policy literature. They are the best epidemiologic evidence of the association between sugar-sweetened beverage consumption and BMI that is currently available.
The suggestion that a message encouraging children and adolescents to consume sugar-sweetened beverages in moderation is naive touches on a much broader debate about the proper way to communicate with adolescents about risk. At least in the United States, there is a long-standing debate over whether it is better to provide children and adolescents with limited information to encourage or discourage a particular behavior or to provide more balanced information to help them gradually learn how to exercise independent judgment. Debates occur regarding the best way to educate children and adolescents about the risks of drugs, tobacco, teen sex, and alcohol use. We believe it is important that the messages delivered to health professionals and the scientific community—who then advise parents, children, and adolescents—reflect the body of scientific evidence. On the basis of the results of our meta-analysis, we do not believe that a message discouraging consumption of sugar-sweetened beverages as a means to reduce the risk of overweight and obesity is justified.
We also note that there is evidence that restricting children's (and presumably adolescents') access to pleasurable foods and beverages makes them even more attractive (5). Because children then view these tasty foods and beverages as "forbidden fruit," they are all the more tantalizing. Teaching youth to enjoy pleasurable foods and beverages in moderation and offering age-appropriate, constructive lessons on reading labels, understanding portion sizes, monitoring caloric intake, increasing physical activity, and making good lifestyle choices seems to be the more sensible solution. Parents, after all, must model the behavior that they wish their children to emulate.
Finally, policymakers need to prioritize which policies will have the greatest impact on obesity as efficiently and as effectively as possible. This means that factors that have the largest impact on public health should receive the highest priority. A policy that targets a factor exhibiting a small, near-zero influence on the problem of obesity will fail to address the problem, yet there will be a cost. One significant cost is the lost opportunity to focus on remedies that are likely to have a larger effect.
ACKNOWLEDGMENTS
MLS is currently senior vice president for Science Policy at the American Beverage Association. RAF is currently a research specialist with the US Food and Drug Administration's Center for Biologics Evaluation and Research. Because of the potential delay for him to obtain the necessary clearance to be included in this response, we have proceeded without listing him as a coauthor of the response.
REFERENCES
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