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PLOS BLOGS Speaking of Medicine

The Sickness Lurking Beneath World Cup Fever

While watching the World Cup, Dean Schillinger was reminded of the ongoing back-and-forth matchup between the soda industry and public health advocates.

Last month, World Cup fever once again gripped the globe. The joga bonito (the beautiful game) celebrates athletic accomplishment on the field, and we all were transfixed. The players’ physical prowess, speed, agility, artistry and magic astounded us. Attacks and counter-attacks that were the hallmark of this tournament made these battles particularly riveting, with fans reacting to each goal as if their lives depended on it.

But there were strikingly incongruous messages and images radiating from these games, generated by a sponsor flaunting and promoting its unhealthy products to a global audience of 3.4 billion people witnessing the wonders of human vitality. Advertising for Coca-Cola, official sponsor of the World Cup and maker and distributor of 60% of the world’s sugar-sweetened beverages (SSBs), attracted more eyeballs than did Messi, Ronaldo or Neymar – combined. Total global advertising expenditures during The World Cup has been estimated at $2.4 billion USD, and Coca-Cola was the market’s dominant spender. As hundreds of millions of people suffering from type 2 diabetes – along with their families and healthcare providers – pleaded for a response to the global epidemic, the World Cup overflowed with Coca-Cola.

The 4 years since Coca-Cola sponsored the last World Cup have been turbulent for the SSB industry. These years have been characterized by unprecedented confrontations between public health advocates and the SSB industry, featuring back-and-forth seesaw battles, with the future of our children’s health held in the balance.  Public health has attacked, enjoying wins on the public relations, legislative and regulatory playing fields. First, a study of conflicts of interest related to research examining relationships between SSBs and metabolic diseases revealed that the SSB industry for years has funded science to prove that their products do not cause obesity or diabetes, while independently funded studies consistently discovered the opposite. Second, the SSB industry and its junk food partners were publicly called to task for paying for a study challenging guidelines that recommend consumers limit added sugar, falsely claiming such guidance is not based on sound evidence. Third, a few countries have implemented beverage labeling policies that clearly communicate to consumers the unhealthy effects of SSBs, and Wikileaks uncovered communications of Coca-Cola’s priorities for countering proposed EU regulations (SSB taxes, warning notices) that would improve health for those in the EU, but adversely affect Coco-Cola’s bottom line. SSB tax initiatives have succeeded in 6 cities in the US and 33 countries; evaluations demonstrate rapid, significant reductions in SSB consumption. Fourth, San Francisco passed the world’s first ordinance requiring warning notices on SSB advertisements, alerting consumers to risks of obesity, diabetes and tooth decay. The American Beverage Association (ABA), a trade organization primarily funded by Coca-Cola, Pepsi and Dr. Pepper-Snapple, sued the city, claiming the ordinance was unconstitutional and infringed on their free speech rights by compelling them to make “controversial, misleading and scientifically false” statements. The industry lost the case.   Finally, the World Health Organization (WHO) declared SSB taxes should be implemented to stem the tide of chronic diseases, the leading cause of death in high-, middle- and low-income countries.

But the SSB industry counter-attacked. ABA attorneys appealed the federal court decision, arguing that warnings are discriminatory insofar as other sugar-containing products, such as cookies and cupcakes, are not required to post such warnings. That over one third of added sugar in the US diet comes from SSBs should provide sufficient rationale for such warnings; the court nonetheless reversed its decision in favor of industry. Only 4 months after Chicago implemented its SSB tax, Cook County Board of Commissioners repealed it after ABA spent millions on ads, lobbyists and political contributions. And now, to avoid spending tens of millions of dollars over and over again fighting local jurisdictions, the SSB industry has resurrected an old legal ploy: pre-emption. Using a strategy of industrial interference resembling Big Tobacco‘s tactics, the SSB industry, through its connections with the current administration, shepherded into NAFTA a proactive provision barring warning notices on SSBs, potentially prohibiting not only cities, counties and states, but entire nations, from enacting such warnings. And this same administration succeeded in removing statements supporting SSB taxes from a WHO document that advises countries grappling with soaring rates of obesity and diabetes. Finally, last month, in a momentum-shifting swing, California – home to 4 million adults with diabetes, plus 9 million adults and half a million children with prediabetes – was held hostage by ABA’s funded effort to put before voters a referendum to make it nearly impossible for local jurisdictions to impose any new taxes, whether they support fire departments, schools, or public health. Fearing this broad-sweeping measure might paralyze cities, the California legislature, with Governor Brown, forced to choose between two bad options, surrendered and signed a “compromise law” banning new SSB taxes in California for 12 years in exchange for the industry dropping the more broad referendum.

As we reflect on the World Cup, one can’t help but wonder: who will win this high-stakes game for the health of the public?  Public health has had only limited assets with which to wage its attacks; in contrast, the SSB industry has harnessed its nearly limitless resources to wage aggressive counterattacks. Only by taking this battle between public health and the SSB industry to a wider playing field – involving a broader coalition and more stakeholders – will the public prevail.

Now is the time. Because We The People have become awake. We The People are responsible for SSB consumption falling to a 30-year low. We now appreciate the difference between Type 1 (an autoimmune disease in which the body attacks itself and stops making insulin) and Type 2 diabetes (a socio-environmental disease in which the body politic attacks its population). We recognize that “Sharing a Coke with a Friend This Summer” carries with it a risk of spreading Type 2 diabetes. That one in four US healthcare dollars is spent on diabetes care alone, and that a family with an income of $50,000 will pay $1,000 in income tax solely to support diabetes care. That our businesses cannot sustain the epidemic’s fiscal pressures and provide us with affordable health insurance. That our AIDS wards have been transformed into diabetes wards. That diabetes affects 425 million adults worldwide and will affect 693 million by 2045 unless we act. Because we have witnessed how “adult-onset diabetes” now affects children at alarming rates, with incidence rates rising by 5% per year.  Because we know that diabetes is the leading cause of blindness in the US and, while ~1,500 soldiers had a limb amputated in the Iraq/Afghanistan conflicts, over 1 million US civilians have suffered an amputation from diabetes in that same period.

Behind the bubbly imagery of the World Cup sponsor lies an ugly truth: that playing soccer – the joga bonito – becomes much more challenging if you cannot see the ball or if you don’t have a foot to kick it with.

We The People are now awake, and we will rise up, and we will win.

About the author: Dean Schillinger MD is a Professor of Medicine at the University of California San Francisco (UCSF), Chief of the Division of General Internal Medicine at Zuckerberg San Francisco General Hospital, and Director of the UCSF Center for Vulnerable Populations’ Health Communications Research Program. He served as Chief of the Diabetes Prevention & Control Program for the California Department of Public Health from 2008-13.

Conflicts of Interest: In 2016, Dr. Schillinger served as a scientific expert for the City and County of San Francisco in its defense against a lawsuit brought by the American Beverage Association and American Billboard Association related to a city ordinance mandating sugary drink advertisements post a warning alerting consumers that drinking sugary drinks can contribute to obesity, tooth decay and diabetes.

Feature image credit: LuckyLife11, Pixabay 

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