Doctors’ Notes


Sugar-Sweetened Beverages

Here are some facts and concerns about sugar sweetened beverages (SSB) to help guide you in considering choices for what you drink.

The purpose of this Doctor’s Note is to educate Kids Plus Families on SSBs, the impact of a specific sugar (fructose), and the concerning economical and physiological impacts of SSBs on children, adults, and ultimately families. Remember: good health starts with good choices, and keeping balance in what we eat, drink, and do physically.

SSBs are defined as beverages containing added caloric sweeteners such as sucrose, high-fructose corn syrup (HFCS), or fruit-juice concentrates.  Examples of these drinks include soft drinks, fruit drinks, sports drinks, energy and vitamin water drinks, sweetened iced tea, lemonade, and Kool Aid.


A significant concern with these drinks is their implication in increased incidence of obesity and metabolic syndrome. In the US between 1977 and 2002, energy intake from soft drinks and fruit drinks increased by 230% and 170% respectively. Sugar in liquid form now accounts for about 35% of total added-sugar intake in the United States. This substitution of drinks displaces the consumption of healthy beverages such as water and milk.

The number of children who are overweight, at risk for obesity, or are obese increases every year. Health care costs attributable to obesity are $150 billion. There is also a parallel rise in obesity and SSB consumption. The percent of total daily calories ingested increased from 3.9% (in late 1970s) to 9.2% in the early 2000s.

There has been a decline in added sugars to food and beverage products in the past few years, but the intake continues to exceed the recommended limits. SSBs contribute more energy to the diet than any other single type of food or beverage. Adolescents consume 13%, and children 10%, of total daily energy intake from SSBs. Unfortunately, SSBs are among the least expensive sources of energy; their cost has only risen 25% as much as fruits and vegetables have. In addition, SSB portion sizes have increased, with the standard serving size from 6.5 oz to 20 oz (a suggested serving size is 8 oz). Some fast-food concessions have serving sizes up to 60 ounces!

Some sugar-sweetened beverages have been heavily promoted in media. In the year 2000 alone, soft drink industry spent >$700 billion in advertisements (an 84% increase since 1986). An additional concern is the targeting of younger age groups with these advertisements. It’s much more difficult to self-regulate energy consumed in liquid form than in solid form. There is a lower satiety effect from the liquid form, and the total amount consumed potentially can be much higher. Some SSBs in the US are sweetened with High Fructose Corn Syrup, leading to a 30% increase in the amount of fructose consumed in the US since 1970.


There are 3 different sugars in a diet – fructose (fruit sugar), glucose (starch), and galactose (milk sugar).

Fructose is metabolized differently than glucose and galactose; it’s completely metabolized in the liver after absorption from gut. Whereas glucose and galactose are regulated by checks and balances in the body (via feedback metabolic pathways),  fructose metabolism is not subjected to a feedback inhibition system in the body. The metabolism is insulin-independent. In a state of vigorous exercise, much of fructose can be utilized efficiently. In a state of stasis (no/slight activity) virtually all ingested fructose is converted through various pathways to low density lipoproteins, leading to increased triglycerides in adipose tissue (causing obesity) and fat in skeletal muscle and liver increasing insulin resistance (leads to diabetes) and lipidemias (problems with high cholesterols).

SSBs can also lead to increases in blood pressures and cardiovascular disease. These beverages reduce the secretion of other body regulators (leptin and insulin) and indirectly promote continued hunger in the part of the brain called the hypothalamus. Caramel coloring in colas may increase insulin resistance as well.

Consumption of SSBs has been implicated in at least 20% of net weight gained in the US between 1977 and 2001. For each additional SSB serving per day, this consumption increases by 60% the odds of a pediatric patient becoming obese.


Limit these beverages more than other junk food that contains protein, fiber, and micronutrients, because they contributes more calories to diet than any other single type of food or beverage. There’s a strong association between SSB intake and excess weight gain. Sweetened beverages are sources of “empty” calories.  Reduction of consumption by 25% has been estimated to lead to net decrease of 4.5 pounds/year in children and 3.8 pounds/year in adults. SSBs contribute to imbalance between caloric intake and energy expenditure.

Families need to support the development of healthy feeding and eating skills — a promotion of eating habits based on variety, balance, and moderation of “empty” calories. It all starts with the entire family following the same guidelines together.

Patients have heard me stress the powerful word “balance” to everything they’re doing with their physical activity and diet.  When selecting something to drink, consider the 1:1 rule – anything you want to drink other than milk or water should be balanced with an equal amount of water. For example: if you want to drink 20 ounces of soda, you must first drink the same amount in water.  If you don’t want to drink that much water, then you must lower your intention of drinking that amount of soda.  Another good habit is to ask for water when you ask for any other beverage at a restaurant or fast food chain. This habit gives you a chance to apply the 1:1 rule to what you’re drinking away from the home. Everyone can do this ratio.

I hope this information helps. Look for more information, here in future Doctor’s Notes, on “problem” foods and what we can do about them.

Dr. Lucas Godinez, a Kids Plus Doc since 2004, spends a lot of time being active and striving for balance, so his expertise on this subject is both personal and professional.