Views & Reviews Personal View

Sugar sweetened drinks should carry obesity warnings

BMJ 2014; 348 doi: (Published 27 May 2014) Cite this as: BMJ 2014;348:g3428
  1. Simon Capewell, professor of public health and policy, University of Liverpool

California is considering health warnings on sugary drinks like those on cigarette packets. Simon Capewell thinks it’s a good idea that the public would support

The California Senate Appropriations Committee is deliberating a bill that would require drinks manufacturers to place the following warning label on all sweetened non-alcoholic drinks: “STATE OF CALIFORNIA SAFETY WARNING: Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay.”1

Under the Sugar Sweetened Beverages Safety Warning Act (the first of its kind in the United States) these labels would apply to any such drink that “has added caloric sweeteners and contains 75 calories or more per 12 fluid ounces.” It would also require vending machines to bear warning labels and would allow for fines of $50 (£30; €37) to $500 (£297; €365) for failed inspections.

This remarkable suggestion raises questions about precedents, public support, and the political feasibility of such a move, as well as about science, public health, industry tactics, and comprehensive health strategies.

Many other potentially harmful products already carry effective health warnings. For example, insecticides and other toxic products have long carried labels warning users to take extreme care. Similarly, cigarettes have gone from being socially acceptable to quite unacceptable after warning labels were implemented. The effectiveness of tobacco warnings and plain packaging is now accepted by almost everyone not linked to the industry.2 These successes in tobacco control highlight the importance of targeting the “three As”—affordability, availability, and acceptability.3 Warning labels clearly target acceptability.

Perhaps the first food warning labels in Europe were Finnish health warnings about salt.4 The United Kingdom’s subsequent “traffic light” labelling of processed foods (to signal high levels of salt, saturated fats, and sugars) aimed to inform consumers and encourage manufacturers to reformulate healthier products.

Public support for warnings about added sugar seems high, suggesting that such labelling is politically feasible. In a recent field poll almost 75% of 1002 bipartisan Californian voters supported the proposed bill.1 And in March 2014 the US Food and Drug Administration suggested adding a separate line on labels to alert consumers to the amount of “added sugars.”

Sugar is being progressively demonised: in the UK, a recent Populus public opinion poll commissioned by the BBC found that about 60% of 1000 adults would support health warnings on food packaging similar to those on cigarette packets. Still more supported banning sugary drinks in schools or limiting the amount of sugar allowed in certain foods. Furthermore, almost half (45%) would support a tax on sugary drinks.5

Many sweetened drinks and fruit juices contain substantial amounts of added sugars. But sugary calories consumed as liquids simply do not provide the same signals of satiety, or fullness, generated by equal calories from solid foods.6

Such sugar sweetened beverages offer an obvious target for policy makers, particularly if similar policies have succeeded elsewhere. Sugary drinks account for as much as 10% of a UK child’s energy intake.7 In one study from several European countries, adults who drank more than one can of sugary soda a day had a 22% higher risk of developing type 2 diabetes than those who drank less than one can a month.8 And because the absolute risk of type 2 diabetes is known to be high, this relative increase in risk is important.

The global obesity epidemic already affects more than two billion adults and children.9 In the UK one third of children and two thirds of adults are now overweight or obese. Although obesity levels may be plateauing in some groups, this is no reason for complacency or prevarication. Obesity increases disease and disability in youth, and subsequent premature deaths can result from type 2 diabetes, cardiovascular disease, and common cancers.9 Sugar is increasingly implicated as a specific causal factor.10

But UK and US policies are failing to reverse trends in obesity. Most obesity treatments currently offered to people, such as advice or preventive medicines, are weak and poorly sustained.11 More effective policies are therefore urgently needed.

Might “calorie control” strategies profit from previous successful lessons in tobacco and alcohol control? Comprehensive “structural” policies to improve the social environment for the entire population have generally proved more powerful than isolated interventions that target individuals. Such population-wide policies can also be rapid, equitable, and cost saving.12 Halving UK and US children’s sugar sweetened beverage consumption could mean a 50-100 kcal (209-418 kJ) reduction in energy intake a day, perhaps arresting or even reversing the current increases in obesity.

In Europe the food and beverage industry recently spent more than €1bn (£813m; $1.37bn) in vociferous attempts to delay, dilute, and demolish food labelling.13 The industry would not do this unless its future profits were threatened (what the pressure group Action on Smoking and Health calls the “squeal factor”).

We might expect the industry to oppose warning labels on sugary drinks with a barrage of opposing arguments, reminiscent of previous opposition to standardised tobacco packaging. Indeed, the big food and soda manufacturers have traditionally used the “SLEAZE” denialism tactics developed by tobacco and alcohol producers.13 14 But most industry arguments will be flawed: threats to pass additional costs on to consumers, predictions of dire reductions in profits or huge job losses, concerns about consumer resistance to change, and so on. In truth, thousands of food and drink products are reformulated and relabelled every year as brands are “refreshed.” And, as already noted, many consumers would support healthier options.

In 2013 the financial services company Credit Suisse published Sugar Consumption at a Crossroads, a report that sent a loud warning to the markets.15 This March, Moody’s credit rating agency lowered its outlook for the global beverage industry from “positive” to “stable,” citing the Mexican government’s soda tax.

And just this month the campaigning group Action on Sugar persuaded the Tesco supermarket chain to write to all of its suppliers asking them to remove all added sugars from children’s soft drinks (Tesco anticipates that most suppliers will cooperate).16 Meanwhile, Co-op stores plan to slash added sugar from their products, and ASDA has agreed that the innovation of healthy new products is “fundamental.”16

Of course, cynics may ask whether, as with tobacco, these industry moves might be pre-emptive—an attempt to preserve profits, wrong-foot competitors, and deflate pressure for more effective regulations. Conversely, less progressive segments of the industry have denounced the health proposals or have exaggerated the (minimal) reformulation efforts already achieved.16

Warning labels for refined sugars hidden in sweetened drinks and processed foods represent an interesting natural experiment. They may offer an effective new strategy for complementing existing, potentially powerful interventions, such as duties on sugary drinks or banning marketing to children.17

These proposals may also herald a tipping point in public attitudes and political feasibilities. Investors, industrialists, and international health groups will all be watching closely—some with narrow financial concerns, and others with broader public health aspirations.


Cite this as: BMJ 2014;348:g3428


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: I am a member of Action on Sugar, a trustee for the UK Health Forum, and a trustee for the UK Faculty of Public Health.

  • I thank Ann Capewell, Katharine Jenner, Kawther Hashem, Mike Rayner, and Jane Landon for their helpful comments.

  • Provenance and peer review: Commissioned; not externally peer reviewed.