To the Editor The May 2016 issue of JAMA Pediatrics juxtaposes 2 research reports that may have more in common than is apparent from their titles. The first reveals racial/ethnic disparities in childhood asthma readmission,1 the second, a possible link between pregnant mothers’ consumption of artificially sweetened beverages and infant obesity.2 Getting to the heart of the “black box” in associational studies of public health phenomena is a longstanding challenge. As the mantra goes, correlation is not the same as causation and may arise from as-yet unknown factors. In the spirit of serendipity, it is worth speculating on a common theme that could potentially be linking these 2 observations; namely, the heavy marketing of sweetened, carbonated drinks (soda) to low-income, largely African American communities in the United States. While the link between high sugar consumption and obesity is clearly established, growing evidence suggests that artificial sweeteners may have similar effects, albeit through other processes.3 In parallel, evidence of a link between asthma and consumption of soda is growing4 while systematic reviews have revealed associations between childhood obesity and asthma that suggest common causes, deprivation being an obvious candidate.5 Efforts by many US states to address this problem through sugar taxes, banning vending machines near schools, and incentivizing retailers to offer healthier alternatives seem to be working in some places. Pennsylvania has been held up as a shining example, and these approaches are now being tried worldwide. However, paradoxically, it appears that an observed decline in soda consumption by low-income children is being mirrored by increased intake of so-called “energy” or “natural fruit” drinks with similar detrimental effects.4 Long-term follow-up data will help to confirm or disprove these trends and influences, but at the very least, the convergence of new evidence and experience suggests that interventions for asthma and obesity need to be a great deal smarter than simply targeting allergens or drug compliance or using artificial sugar substitutes.3 The global “pushing” of soda bears remarkable similarities to that of tobacco, and its effects do not stop at the US border, nor, indeed, with those who happen to be African American, although they do hurt the poor disproportionately. The stealth marketing of unhealthy alternatives is also worth attention.
Pagliari C. Artificially Sweetened Beverage Consumption During Pregnancy and Infant Body Mass Index. JAMA Pediatr. 2016;170(11):1116-1117. doi:10.1001/jamapediatrics.2016.2813