PERSONAL VIEW

Sugar sweetened drinks should carry obesity warnings California has had the right idea in considering health warnings on sugary drinks, writes Simon Capewell

he California Senate Appropria- have traditionally used the “SLEAZE” denial- tions Committee is deliberating ism tactics developed by tobacco and alcohol a bill that would require drinks producers.13 14 But most industry arguments manufacturers to place the follow- will be flawed: threats to pass additional costs ing warning label on all sweetened on to consumers, predictions of dire reductions Tnon-alcoholic drinks: “STATE OF CALIFORNIA in profits or huge job losses, concerns about con- SAFETY WARNING: Drinking beverages with sumer resistance to change, and so on. In truth, added sugar(s) contributes to obesity, diabetes, thousands of food and drink products are refor- and tooth decay.”1 mulated and relabelled every year as brands are Under the Sugar Sweetened Beverages “refreshed.” Safety Warning Act (the first of its kind in the In 2013 the financial services company Credit United States) these labels would apply to any Suisse published Sugar Consumption at a Cross- such drink that “has added caloric sweeteners roads, a report that sent a loud warning to the and contains 75 calories or more per 12 fluid markets.15 This March, Moody’s credit rating ounces.” It would also require vending machines agency lowered its outlook for the global bever- to bear warning labels and would allow for fines age industry from “positive” to “stable,” citing of $50 (£30; €37) to $500 for failed inspections. the Mexican government’s soda tax. Many other potentially harmful products And recently the campaigning group Action already carry effective health warnings. The on Sugar persuaded the Tesco supermarket effectiveness of tobacco warnings and plain chain to write to all of its suppliers asking them packaging is now accepted by almost everyone to remove all added sugars from children’s soft not linked to the industry.2 These successes in drinks (Tesco anticipates that most suppliers tobacco control highlight the importance of tar- one can of sugary soda a day had a 22% higher will cooperate).16 Meanwhile, Co-op stores plan geting the “three As”—affordability, availability, risk of developing type 2 diabetes than those who to slash added sugar from their products, and and acceptability.3 Warning labels clearly target drank less than one can a month.8 And because ASDA has agreed that the innovation of healthy acceptability. the absolute risk of type 2 diabetes is known to new products is “fundamental.”16 Public support for warnings about added sugar be high, this relative increase in risk is important. Of course, cynics may ask whether, as with seems high, suggesting that such labelling is But UK and US policies are failing to reverse tobacco, these industry moves might be pre- politically feasible. In a recent field poll almost trends in obesity. Most obesity treatments cur- emptive—an attempt to preserve profits, wrong- 75% of 1002 bipartisan Californian voters sup- rently offered to people, such as advice or preven- foot competitors, and deflate pressure for more ported the proposed bill.1 And in March 2014 the tive medicines, are weak and poorly sustained.11 effective regulations. Conversely, less progressive US Food and Drug Administration suggested add- More effective policies are therefore urgently segments of the industry have denounced the ing a separate line on labels to alert consumers to needed. health proposals or have exaggerated the (mini- the amount of “added sugars.” Might “calorie control” strategies profit from mal) reformulation efforts already achieved.16 Sugar is being progressively demonised: in the previous successful lessons in tobacco and alco- Warning labels for refined sugars hidden in UK, a recent Populus public opinion poll com- hol control? 2 Halving UK and US children’s sugar sweetened drinks and processed foods repre- missioned by the BBC found that about 60% of sweetened beverage consumption could mean sent an interesting natural experiment. They may 1000 adults would support health warnings on a 50-100 kcal (209-418 kJ) reduction in energy offer an effective new strategy for complementing food packaging similar to intake a day, perhaps arrest- existing, potentially powerful interventions, such those on cigarette pack- Public support for warnings ing or even reversing the cur- as duties on sugary drinks or banning marketing ets. Still more supported about added sugar seems rent increases in obesity. to children.17 banning sugary drinks high, suggesting that such In Europe the food and These proposals may also herald a tipping in schools or limiting the labelling is politically feasible beverage industry recently point in public attitudes and political feasibili- amount of sugar allowed spent more than €1bn ties. Investors, industrialists, and international in certain foods. Furthermore, almost half (45%) (£813m; $1.37bn) in vociferous attempts to health groups will all be watching closely. would support a tax on sugary drinks.5 delay, dilute, and demolish food labelling.13 Simon Capewell is professor of public health and policy, Sugary calories consumed as liquids simply do The industry would not do this unless its future University of Liverpool not provide the same signals of satiety, or fullness, profits were threatened (what the pressure group [email protected] 6 Competing interests: I am a member of Action on Sugar, a generated by equal calories from solid foods. Action on Smoking and Health calls the “squeal trustee for the UK Health Forum, and a trustee for the UK Faculty Such sugar sweetened beverages offer an factor”). of Public Health. obvious target for policy makers, particularly if We might expect the industry to oppose warn- I thank Ann Capewell, Katharine Jenner, Kawther Hashem, Mike similar policies have succeeded elsewhere. Sug- ing labels on sugary drinks with a barrage of Rayner, and Jane Landon for their helpful comments. Provenance and peer review: Commissioned; not externally ary drinks account for as much as 10% of a UK opposing arguments, reminiscent of previous peer reviewed. 7 child’s energy intake. In one study from several opposition to standardised tobacco packaging. References are in the version on thebmj.com. European countries, adults who drank more than Indeed, the big food and soda manufacturers Cite this as: BMJ 2014;348:g3428

| 19 July 2014 23 LAST WORDS

NO HOLDS BARRED Margaret McCartney Overprescribing antidepressants: where’s the evidence?

Is the United Kingdom in the grip of Is this true? The paper he referred people receiving antidepressants.” an antidepressants epidemic? We are to was a population based cohort And a study published in 2009 found certainly gripped by an epidemic of study, capable of finding association that the proportion of antidepressant the media writing about them. The but not causation.4 And the council prescriptions given to people with past few months have seen reports said that antidepressant use had a new diagnosis of depression of more antidepressants being increased by 92% in England since was constant from 1993 to 2005— used during the financial crisis,1 20035; however, it cited the Health making it unlikely that more people stories of how many people seem to and Social Information Centre, which with symptoms of depression were be taking them,2 and an article in records prescription items rather than treated with antidepressants during by Peter Gøtzsche—a prescription amounts.6 that timeframe.9 member of the newly formed Council Over the past Over the past decade GPs have I have little doubt that overdiagnosis for Evidence Based Psychiatry, decade GPs been told to prescribe tablets monthly occurs. And I have no illusions about which aims “To reduce psychiatric have been told rather than, as previously, an amount the effectiveness of antidepressants harm by communicating the latest that would last 2-3 months.7 The in mild to moderate depression. But 3 to prescribe evidence.” tablets monthly number of items dispensed is likely big data can mean big problems, “It’s hard to believe that so many to have increased as a result—but and this can pose more questions people have become mentally rather than, as it is uncertain, from the data cited than it answers. Failing to pay disturbed and that these prescription previously, an by the Council for Evidence Based attention to uncertainties and caveats increases reflect a genuine amount that Psychiatry, whether this means that means that we can overshoot the need,” said Gøtzsche. He blamed would last 2-3 more people are taking them. evidence, and this can cause harm overdiagnosis, conflicts of interest months Similarly, a report by the Health through the under-recognition and among the writers of the Diagnostic Foundation and the Nuffield undertreatment of mental illness. and Statistical Manual of Mental Trust, which found an increase Margaret McCartney is a general practitioner, Disorders, and the illegal marketing in antidepressant use during the of psychiatric drugs. He concluded, recession, analysed prescription cost [email protected] “Another report said that, amongst data.8 But it concluded, “We cannot Competing interests: See thebmj.com people over 65, antidepressants are determine whether these trends are Provenance and peer review: Commissioned; not believed to kill one out of every 28 based on the same people receiving externally peer reviewed. people treated for one year, because Twitter more medication, or whether they References are in the version on thebmj.com. they lead to falls and fractures.” ̻̻@mgtmccartney reflect an increase in the number of Cite this as: BMJ 2014;348:g4218

BMJ BLOG OF THE WEEK William Cayley When it’s awkward

“I just hate this sort of thing.” When they probably already are, and comfort my conversation may have badly, an expensive medication I overheard that at a recent funeral, broaching the topic may actually offered. misprescribed). as we waited in line to greet the be more of a source of comfort that As medical professionals, we are It’s important to keep our bereaved family, I thought to myself, someone is actually listening, rather called (I was going to say “trained” emotional perceptions tuned in to “How sad . . . and how true.” Sad, than a distressing introduction of a but maybe our training for this is not when we feel the most awkward. Is it because times of grief are when new worry. the best) not simply to care for our the angry patient? Is it the mistaken others need us most, but also true, Right now, I know two people patients, but to help them deal with diagnosis? Is it the bereaved spouse? because most of us find talking with facing imminently terminal cancer. the tough stuff. Listening to our own inner sense the grieving awkward, and we don’t While driving home recently, I We should be able to discuss of discomfort can be a decent like it. thought about making a quick phone risks, benefits, evidence, and indicator as to when a patient is Before entering medicine, I trained call to one of them for a check-in, numbers needed to treat, but also in particular need of comfort or as a hospital chaplain. One of my then my next thought was how tired be there to journey with our patients support. When it’s awkward, that’s wise teachers impressed on me the I was, and that I may not be ready through the awkward patches. And when they need us most. principle that—when talking with for a potentially emotional phone this applies whether those awkward William E Cayley Jr practises at the Augusta patients—if something difficult, call. In the end, I did call and was patches are of the patient’s making; Family Medicine Clinic; teaches at the Eau challenging, or awkward about the glad I did, but I realised later that are seemingly random “bad luck” Claire Family Medicine Residency; and is situation crosses your mind then the had I hesitated and not called, my events (a cancer diagnosis, death of a professor at the University of Wisconsin, patient is probably already aware of it. feeling of awkwardness over the a family member); or even awkward Department of Family Medicine For example, if you think a patient hard situation my friend faces could moments of our own making (a ̻̻Read this blog in full and other blogs may be concerned about cancer, have robbed him of whatever small missed diagnosis, a procedure gone at thebmj.com/blogs

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