Depending on your point of view, Richmond’s proposed Sugar Sweetened Beverage Tax is either:
- A creative and cutting edge initiative to improve the health of a community, particularly youth, who suffer unusually high levels of obesity and diabetes.
- A sinister plot to enrich the general fund at the expense of retailers, poor people and minorities.
In any event, I believe I did the right thing to vote to place this on the ballot and give the people the power to decide.
The following makes some interesting reading about Richmond that people are paying attention to all across the country. It’s certainly better than reading about crime or a burning refinery.
See http://bittman.blogs.nytimes.com/2012/10/10/a-cardiologist-makes-the-case-for-taxing-soda/, http://bittman.blogs.nytimes.com/2012/10/10/a-cardiologist-makes-the-case-for-taxing-soda/ and http://bittman.blogs.nytimes.com/.
October 10, 2012, 12:00 pm
A Cardiologist Makes the Case For Taxing Soda
By MARK BITTMAN
Jeff Ritterman is a cardiologist, a member of the Richmond, California, City Council and a leader in the proposal to institute a penny-per-ounce soda tax in Richmond, a measure that’s being voted on by the Richmond electorate May 6. (See my column of October 9.) This is a minimally edited transcript of an interview I did with him about a month ago, which is notable for both its scientific and political clarity. (And thanks to Jennifer Mascia for transcribing.)—MB
Mark Bittman: Why a soda tax? Why now?
Jeff Ritterman: The challenge concerning Richmond is, O.K., we’ve got this tremendous problem. If we do nothing, children are going to lose years of life. It’s not their fault. They don’t even understand it. And what would a successful intervention be? If you comb the medical literature, you find that Dr. Thomas Frieden, the director of the Centers for Disease Control and Prevention, who is essentially the country’s leading doctor for prevention, has said that the sugar-sweetened beverage tax is “the single most effective measure to reverse the obesity epidemic.” And the California chapter of the American Academy of Pediatrics, which is the professional organization that represents the children’s doctors of California, has strongly endorsed our measure, and their letter says they “applaud the Richmond city council on behalf of the health of the children of California.”
MB: Why don’t you tell me about how the measure came about and where things stand?
JR: I’m on the Richmond City Council. I started in January of 2009, and basically my interest in getting on the council was to take public health and population health data and science and figure out a way to formulate social policy. As a cardiologist I could help improve the health of Richmond one patient at a time, but now I have the opportunity to lift up the entire community’s health with policy. The first example of us doing that was with cigarette policy. We had a failing grade from the American Lung Association when I came on the council, and I asked them how to get a better grade, and they said to rewrite our tobacco prevention ordinances, and we did that, and now we’re the model for the state. So we have a history of what they’re calling in the medical field now “translation”—taking research from the lab to the clinic to the community—and we’re trying to do the same thing with sugar-sweetened beverages. So we’ve put it on the ballot. California has a referendum system, so the voters of Richmond on November 6 will vote up or down, yes or no if they want a soda tax. It’ll be one cent per ounce.
MB: Did you have to do a petition to get it on the ballot?
JR: No, we have five out of seven city council members’ support. So if the City Council passes it, it goes on the ballot. The other method is signatures. Even before we put it on the ballot, the American Beverage Association was in town meeting with me and others, and they will probably spend over a million dollars to try to defeat this measure, which shows how important it is to them.
MB: If I were them, I’d spend $20 million to defeat it.
JR: I think they’ll spend as much as they feel like they have to. Last week, Willie Brown was here speaking against us and somebody paid his fee, and I’m pretty sure it came from big soda but I don’t know that for sure. So they’re spreading a lot of money around, and I think they’re going to lose. I think we have really incredible support. Every week there’s a news article that comes out. This past week the New England Journal of Medicine had, I think, four or five articles on sugar-sweetened beverages. So basically every week there’s some very damning study to come out. And we have in our area the benefit of having some of the world’s experts. Professor Jean-Marc Schwarz, he teaches at UCSF and is one of the world’s experts on fructose metabolism and he’s been advising me. And basically what he shared with me is that in one week, by feeding healthy volunteers sugar-sweetened beverages instead of bread and crackers, you can induce fatty liver and the production of fats that are markers for early coronary disease. And a lot of that’s been published already. You’ve probably seen the 60 Minutes piece with Rob Lustig. And Kimber Stanhope. Rob and Claire Brindis and Laura Schmidt are all advising me, and Elissa Epel, who’s local and and an expert on food addiction, and Kelly Brownell from Yale— all of them have been very helpful. And Harold Goldstein from California Center for Public Health Advocacy, and a couple weeks ago I met with Mayor [Michael] Nutter of Philadelphia to get his advice.
So we’ve got a lot of support, but it’s really a grassroots effort. We have a grassroots movement here, going door to door, calling people on the phone, putting out lawn signs and town hall meetings. I’m speaking wherever I can. We need to raise a lot of money. I’d love to direct people to our webpage, Fit For Life.
So the science is all in our favor but the science is not well known. The problem is that most people think that this is a safe beverage to drink, and yet in this past year in Circulation there’s an article that says one serving a day increases a man’s risk of heart attack by 20 percent, and in those who have one serving a day you can find in their bloodstream markers that show they’re at risk for a heart attack.
I think our job is to really explain to the public that this idea that any food or beverage can be a part of a healthy diet is no longer true, and also to explain to the public that you reach for a soda in response to thirst, not in response to hunger, so all of these arguments that there’s sugar in a donut or whatever are actually irrelevant. Because in the body, the systems are totally different. The waste streams are different. The hormones are different. The organs involved are different. When you drink a sugar-sweetened beverage, the reason that the calories don’t register is because the body sees it as water. There is no digestion—it doesn’t need gastric acid, it doesn’t need pancreatic juice, it doesn’t need bile, it doesn’t need any of these things to digest. It just
goes right from the small intestine and it goes two places.
Remember, whether it’s sucrose or high fructose corn syrup, it’s really two molecules: a glucose and a fructose molecule. And herein lies the real problem, because it’s a double whammy. Glucose goes right into the bloodstream, and you get an insulin response, so now you’ve got elevated insulin levels. And when you’ve got elevated insulin levels you deposit fat and cannot use your fat stores…
So the glucose predisposes to fat deposition, not fat breakdown. The fructose goes right to the liver, in huge doses. And the liver puts some of it in glycogen and pushes some of it into the bloodstream in glucose and puts some of it in the mitochondria for the Krebs Cycle, but it’s got a huge amount left over, and all of that gets converted to fat, and therein lies the problem. And it’s not the fat we see that is the problem. It’s not that people get fat and then the fat predisposes them to diabetes, heart disease, cancer and all these things. It’s one process—we have fat storage disease that predisposes us to all these things that have now been classified as metabolic syndrome, plus cancer.
So you get a kid who drinks a Big Gulp, who’s got this huge hit of fructose in the liver, the liver is converting it to triglycerides, which get deposited everywhere. But not only in the abdomen and in the subcutaneous tissue, where you see it, but also in the liver and the muscles and the heart. So our organs get fatty, and the fatty liver gets insulin resistant. That’s one of the dysfunctions which comes with fatty liver, and that insulin resistance continues to drive the system, because the pancreas responds to the liver as if the liver was hard of hearing—it can’t hear the signal from insulin. So the pancreas starts shouting, metaphorically, it puts out higher and higher levels of insulin. And therein comes the problem with the pancreas overworking,
eventually pooping out, and that’s where the diabetes comes from.
So that’s all a part of the same process. There’s a linkage to hypertension, through the nitrous oxide cycle that also happens, there’s a linkage with cancer because these high insulin levels predispose cancer cells, which have lots of insulin receptors to preferentially take up the glucose rather than your own cells, so it promotes cancer growth.
And in addition, non-alcoholic fatty liver disease is a consequence of this excess fructose, and Rob [Lustig] told me that in the next generation, non-alcoholic fatty liver disease from too many sugar-sweetened beverages is going to be the leading cause for liver transplant. At the same time the liver is making all this fat, it’s making small, dense LDL particles—I spent 30 years of my life fighting against them—that cause premature heart attacks; they’re what causes coronary blockages. So you get a whole cascade of responses at the same time you’re making bad body fat that basically implicate all of the leading causes of death—complications of diabetes, premature coronary artery disease, the same process in premature coronary artery disease causes stroke, hypertension predisposes to stroke, and then you’ve got the cancer linkage.
So all of a sudden, a beverage we grew up thinking was “the real thing,” it’s cool, it’s what the athletes drink, even Gatorade quenches your thirst after a big run or whatever—we’re now learning that all that sugar is causing harm. If you think about it for a second, you realize if you take the perspective of evolutionary biology, we’re really not who we think we are. My liver is not really any different than the liver of the hunter-gatherer. In fact, 99.5 percent of our time on this earth has been before agriculture. And so all of the components that comprise my physiology are the same as the hunter-gatherers. The only exception I can think of is that we can digest cow’s milk, and they can’t, I don’t think.
MB: You said you were confident you were going to win. Why do you think that?
JR: I think we’re going to win because when we’re knocking door to door, we’re getting a very positive response. Truth and science is on our side, and I think eventually that’ll get through. But also because they seem to be worried. On the other side they’re escalating their spending, they’re lying, they’re attacking me personally now. And they have polling data, so I assume they’re constantly polling. And they’re push-polling. They’re saying, “If you knew that the soda tax was going to make all the businesses bankrupt in Richmond, would you vote for it?” Something like that. So that’s why I think we’re going to win.
60 Minutes, American Academy of Pediatrics, American Beverage Association, American Lung Association, Big Gulp, California, California Center for Public Health Advocacy, Centers for Disease Control and Prevention, Circulation, City Council, Claire Brindis, Dr. Thomas Frieden, Elissa Epel, Fit For Life, Gatorade, Harold Goldstein, Jean-Marc Schwarz, Jeff Ritterman, Jennifer Mascia, Kelly Brownell, Kimber Stanhope, Krebs Cycle, Laura Schmidt, Michael Nutter, New England Journal of Medicine, Richmond, Rob Lustig, UCSF, Willie Brown, Yale
From Mark Bittman
Mark Bittman October 9, 2012, 9:30 pm107 Comments
The Domino Theory, Redux
By MARK BITTMAN
Mark Bittman on food and all things related.
Imagine you had a multibillion-dollar industry that was (a) enormously profitable and (b) under frequent attack from public health researchers because (c) it’s demonstrably bad for the health of your customers.
This was, of course, the story of the tobacco industry, and it is – right now – the story of the sugar-sweetened beverage industry. Like the cigarette makers, the peddlers of soda cannot do much about any of this: they owe it to their shareholders to maintain those profits, and the products they sell evidently cannot, no matter how hard they try, be tinkered with to change factors (b) and (c). 
Even if the beverage industry were composed of the nicest people in the world, it will not stop marketing to children unless it’s made to; indeed, these marketing efforts are within the rules of the game, however deadly they may be. The outcome of those rules and the marketing they allow is pandemic obesity and all the costs associated with it, which have been detailed enough elsewhere to pass over here.
The goal of right-thinking people, then, is to change the rules and somehow make it more difficult for the marketers to do their job. This can be done by legislation, executive mandate or — in some places, like California — referendum. Legislation to impose a significant tax on soda — a penny or even two per ounce – has failed everywhere, though it’s come close, especially in Philadelphia. After failing to pass legislation for a soda tax, Mayor Michael Bloomberg proposed (and will evidently institute, five months from now) a ban on large sizes of soda in many New York City places.
Now the California cities of Richmond and El Monte have put the soda tax — which has been endorsed by the United Nations, the American Heart Association, the American Medical Association, The New England Journal of Medicine, the Institute of Medicine and many others, and which the Centers for Disease Control and Prevention commissioner, Thomas Frieden, has called “the single most effective measure to reverse the obesity epidemic” – on the Nov. 6 ballot.
A Cardiologist Makes the Case
Both of these are working-class, largely nonwhite cities, with populations of about 100,000. Richmond  , ranked sixth-most-obese city in the state, is in the East Bay, north of Berkeley; El Monte – which ranks ninth – is just east of Los Angeles, in the I-10 corridor. Were either to institute a soda tax, the prediction here is that some or even many nearby cities would follow suit quickly, for two reasons. The first, almost immediate, is that these nearly broke municipalities would each gain a new source of income that could, according to the soda tax calculator developed by the economist Tatiana Andreyeva of the Rudd Center in New Haven, be about $3 million annually . 
The cities must decide how to spend these small windfalls. Dr. Jeff Ritterman, a retired cardiologist serving on the Richmond City Council, says that “for $86,000 we can teach every third grader how to swim at one of our municipal pools, and for $800,000 we can put a nutrition-gardening-cooking instructor in each of our 10 elementary schools.”
The longer-term benefit, which may take a year, or three, or even five to become evident and accepted, is health. Studies have shown that reduced soda consumption results in reduced weight. How quickly and how significantly a soda tax would reduce consumption remains to be seen. But without this kind of intervention, says Ritterman, “Our adult obesity rate will go from 24 percent to 42 percent when the present fifth and seventh graders reach adulthood.”
There’s a third reason other cities will follow suit, and that’s reputation. As a local observer said to me, “You don’t think San Francisco is going to be out-done by Richmond, do you?”
For all of these reasons, the first city to institute a soda tax will gain historic relevance and begin a kind of domino effect that proponents of public health can get behind. But it’s not going to happen without a struggle; remember, the beverage industry has no choice.
And while the proponents of the tax are largely volunteers, public health proponents and well-intentioned politicians (not an oxymoron!), the beverage industry has the bucks, and is spending them at a rate of about 100 to 1, in Richmond, at least: according to Ritterman, as of last week the industry had spent $2.2 million getting out the “no” vote; supporters had raised $34,000 and spent $29,000. 
Though Ritterman is optimistic (“We’re going to win because truth and science are on our side”), El Monte’s mayor, Andre Quintero, is more cautious: “The industry is spending very aggressively here: they have every single possible tool you can imagine having at their disposal.”  El Monte, also, is a small city of less than 10 square miles, so businessmen argue that it’s easy for their customers to leave to buy soda (or to eat, and order soda with a meal) in a neighboring town. “But,” says Quintero, “even making that conscious decision — I’m going to step out of the boundary to get my sugary drinks — is going to work on the person and make them think, Is this a choice I really need to make?”
That’s the spirit: changing the rules to give people a reason to think, to consider, should change their behavior. The New York experiment may be effective, but most experts believe a tax is the way to go. Whether it’s Richmond, El Monte, both, or someplace else, the first city to institute a soda tax will be the first domino to fall and eventually gain the gratitude of the rest of the country.
1. I’ll just call this “soda” from now on, but equally culpable are sugar-sweetened iced teas, so-called fruit juices, so-called sports drinks, so-called energy drinks, sweetened waters, coffee drinks with a calorie content like that of a banana split and anything else that has more sugar than you could ever imagine pouring into a cup of coffee. Just FYI, a 12-ounce soda contains up to 10 teaspoons of sugar; 12 ounces of Snapple is about the same; in fairness, Gatorade has “only” a little more than half as much sugar as that. A “tall” Frappuccino, by the way, contains 8 teaspoons of sugar.
2.This isn’t a matter of building safer cars and putting seat belts in them, or of engineering cell phones so they won’t receive texts while you’re driving (that’ll happen). At some point a wildly popular and safe substitute for sugar may be found, but at some point a safe cigarette might be invented, or indeed a pill that will allow you to eat supersized cheeseburgers, fries and cokes twice a day, and not gain a pound. The winning ticket in those lotteries is worth billions if not trillions of dollars, and “they’re” working on it, but “they’re” working on energy from fusion, too.
3. Home of Rosie the Riveter National Park!
4. El Monte is one of those rare cities that actually has a municipal health and wellness plan, and it recently banned sodas from its park and recreation facilities.
5. The same calculator tells us that a penny-per-ounce tax in Los Angeles would reap more than $113 million in its first year.
6. A measure to force those working against the tax to disclose their funding sources was passed by the city council and successfully challenged by the industry.
7.This includes referring to the soda tax as if it were a grocery tax, implying that soda = food, which it decidedly does not. See my column, What Is Food?