Pour better or pour worse: how beverages stack up.

Q: Why did you organize a panel of experts to advise people about what to drink?

A: People don't understand that beverages are less satiating than solid foods. When you consume calories from beverages, you don't compensate by eating less food later on. Liquid calories don't register with our appetite controls.

The second reason was that schools are dropping soft drinks from vending machines and adding sports drinks or juices or sweetened milk drinks instead. But kids may not be gaining anything by those changes. The industry is just playing games. We felt that people needed to know how the whole array of beverages affects health.

Q: Do we get many calories from beverages?

A: Yes. Today the average American gets about 21 percent of his or her calories from beverages. Most age and gender groups are consuming about 150 to 300 more calories than they did 30 years ago, and about half of the increase in caloric intake comes from soft drinks and fruit drinks.

Q: That's a big change?

A: Yes. From the 1970s to the present, per capita intake of soft drinks and fruit drinks went up, the number of times per day that people consumed calorically sweetened beverages went up, the portion size went up, and the percentage of people consuming those beverages went up. So we've had huge changes in the last 25 or 30 years.

Q: Have soft drinks contributed to the obesity epidemic?

A: Soft drinks and fruit drinks are clearly a bigger culprit than any other beverage for 10-to-35-year-olds. But all beverages with calories have contributed. There are groups of adults who have tripled their daily alcohol intake, and others who have started having a smoothie a day.

Q: How do beverages make us gain weight?

A: Studies show that you gain weight if you shift from noncaloric beverages to calorically sweetened ones. We think that's because if you drink a beverage--whether it's a soft drink or juice or beer--you don't compensate by eating less food later.

Q: Does drinking water change your food intake later?

A: No. Since we evolved getting our calories only from food, it makes sense from an evolutionary perspective that drinking water wouldn't limit your food intake. It would be dangerous if people were no longer hungry after drinking water, because they wouldn't consume enough food. We were built to have separate thirst and hunger mechanisms because the body needs both fluids and calories from food. Throughout evolution, fluids had no calories.

Q: Do the calories in soup register?

A: We didn't address soup or meal drinks like Ensure. But soup is different from beverages. As you go from a beverage to a soup to a solid food, you tend to compensate for the calories by eating less later. Nobody quite understands why beverages are remarkably different from foods, even liquid foods such as soup.

Q: Can you get by with just water?

A: Yes, water is all we need if we have a healthy, balanced diet. Paleolithic humans lived on breast milk and water. One to two thousand years ago, we started to consume beer and, much later, other alcoholic beverages. A few hundred years ago, when coffee and tea were introduced, people put a little sugar in them. Those were the major caloric beverages out there, along with some local juices off of trees.

We didn't really get many calories from beverages until the last century, when more sweetened teas and coffees, and then soft drinks, came in after World War II. So we are in a new world when it comes to beverages. We've really shifted over time.

Q: If you don't eat a healthy diet, you might need more than water?

A: Right. In modern society, many age and gender groups need other beverages like milk to supply nutrients they don't get from food. And, thanks in part to marketing, we want other beverages like alcohol, coffee, and soft drinks.

Q: Do we get enough liquids?

A: It's not clear. The Institute of Medicine says we get enough. But the IOM based its recommendation on national averages. It didn't look at the distribution to see who got too little and who got too much. A few studies indicate that a sizeable number of Americans don't get enough fluids. However, there is no accepted method of measuring hydration, which may be why the IOM really didn't examine this issue.

Q: What about the elderly?

A: The frail elderly, in particular, don't drink enough beverages. Some are afraid they'll fall on the way to the bathroom at night, or even during the day.

And 10 to 20 percent of Americans have diabetes. According to some estimates, three-quarters of them don't have their blood sugar tightly controlled. That may cause a shrinking of cells and dehydration.

Q: Would drinking more liquids help people with diabetes?

A: We don't know for sure, but limited research suggests that the answer is yes.

Q: Does too little liquid harm the kidneys ?

A: Yes. Drinking more liquids is associated with a lower risk of kidney stones in many studies. And with chronic dehydration, the risk of bladder cancer goes up. But it's not well understood. We have ignored water in health and diet research for the last century.

Q: Do we really need eight glasses of water a day?

A: It's variable. Some people need 20 glasses of liquid a day, and water is best. But others may need only four glasses a day. It varies with age, gender, metabolism, and diet. Some vegans get a lot of water in fruits and vegetables, while meat eaters get less. But at a minimum, increasing your water intake decreases your caloric beverage intake.

Q: After water, should we drink mostly tea and coffee?

A: Tea and coffee aren't number two for nutrients, but they are number two for how much we should consume because they don't have many calories. Unsweetened tea and coffee are good water replacements, within limits.

Q: No sugar at all?

A: The panel didn't get into nuances, but a teaspoon or two of sugar in a cup of coffee or tea fits in the same category as unsweetened. Each teaspoon of sugar has 16 calories. Two-thirds of the tea that Southerners consume doesn't have much sugar. It's only when you get to the lattes and super-sweetened teas that they're like a soft drink, with 100 to 200 calories or more. [See "Drink to Me Only," p. 7.]

Q: Does tea prevent disease?

A: We don't know. A 15-year study of men found no lower risk of heart disease in those who drank tea, but the average man drank only a cup a day. A study of women found a lower risk of heart disease in the small number who drank more than four cups of black tea a day. Another study found that tea helps arteries dilate, which could explain how it may protect the heart.

So the evidence is intriguing, but we have no proven results that the flavonoids and other antioxidants in tea have human health effects. Our committee felt quite strongly that the evidence was insufficient.

On the other hand, drinking tea can't hurt, unless you fill it with sweeteners. And tea has half the caffeine of coffee or less. [See "The Buzz," p. 6.]

Q: Is coffee good for you?

A: In contrast to tea, human studies have found that coffee drinkers have a lower risk of diabetes and Parkinson's disease. So coffee has some limited health benefits, certainly more than most beverages other than milk and alcohol.

But caffeine is a concern for pregnant women, because intakes over 300 milligrams a day have been linked to an increased risk of miscarriage and low birth weight. And sensitivity to caffeine goes up with age.

Q: Does caffeine have benefits?

A: Yes. If you consume a small amount of caffeine, your mental acuity, physical performance, reaction time, vigilance, visual processing, and even your mood state improves. Caffeine's benefits are quite well documented in careful studies.

But after a certain amount of caffeine--400 mg or 500 mg--you get adverse effects on performance and mood. And the effects are stronger in older people. So we recommend four cups of unsweetened coffee or eight cups of unsweetened tea per day, maximum. Those are 8-ounce cups. A 20-ounce venti cappuccino has 270 mg of caffeine, according to Starbucks.

Q: What are milk's benefits?

A: Fat-free and low-fat milk fill major gaps in nutrients. They supply a number of nutrients--like calcium, magnesium, potassium, and, because of fortification, vitamin D--that we don't get from other foods. If you can't consume milk, fortified soy milk has many of the same benefits.

Our panel only recommended fat-free or 1% fat milk or fortified soy milk, not whole or 2% fat milk.

Q: What about sweetened soy milk or chocolate milk?

A: We recommend only plain soy or cow's milk. When it's chocolate or fruit flavored, the calories go up. The fat in soy milk is higher than in fat-free or low-fat cow's milk, but it's not a saturated fat. And soy milk has less naturally occurring sugar than milk.

Q: Does milk prevent weight gain, as the industry's ads claim?

A: Just like the Institute of Medicine and the Dietary Guidelines committee, we didn't feel that there was strong evidence that consuming milk leads to weight loss. It remains to be proven.

Q: Does milk protect bones?

A: In adults, we don't find a relationship between milk and bone density, possibly because adults don't drink much milk. In children, studies often find greater density in milk drinkers, at least in some bones. But the benefits of milk on bone density don't necessarily continue if you curb your intake, so you've got to keep at it.

Q: How much milk does the panel recommend?

A: Up to two cups of skim or 1% fat milk a day, and maybe more for children and adolescents. That's the biggest disagreement we had with the Dietary Guidelines Committee. It recommended three servings, but we stopped at two because of the calories.

Q: Does your advice disagree with the diet in the Dietary Approaches to Stop Hypertension, or DASH, study?

A: Our recommendations don't disagree with the DASH diet, because DASH recommends two or three servings a day of low-fat dairy products, including yogurt, cheese, and milk. If you consume low-fat yogurt or cottage cheese, you eat less food later. When you drink milk, you don't.

Q: What about whole milk?

A: We don't think anyone school-aged or older should consume whole or 2% fat milk. Americans don't need the saturated fat, and we know that whole fat and 2% fat dairy products are a big source of saturated fat in our diets.

Q. Did the panel endorse diet drinks?

A: We were very cautious about saying that you can consume a lot of diet drinks, because a few studies suggest that these beverages condition children and adults to have a high preference for sweetness. But it hasn't been studied much, so we don't know if it's true.

Q: Have studies tested diet versus regular soft drinks on weight?

A: Yes. The best clinical study gave artificially sweetened drinks to about 20 overweight people and sugar-sweetened drinks to another 20, but no one knew which they were getting. After 10 weeks, the diet soft drink group lost about 2 pounds and the regular soda group gained about 3 1/2 pounds.

So we felt that it's better to consume diet drinks than regular soft drinks, fruit drinks, etc. And we didn't think there was much evidence against the safety of any of the FDA-approved sweeteners. But, again, we were cautious about the possibility that diet drinks condition people to prefer sweets.

Q: Where do fruit juices come in?

A: They're among the beverages that may have health benefits, but that also have a lot of calories. Fruit juices have a small nutritional benefit, but they're as calorically dense as any soft drink or fruit drink.

We don't want people to consume more than a third of their daily intake of fruit as juices. Less than a third is better. And the fruit smoothies you can buy in stores and restaurants are in the same category. A half to a whole glass--four to eight ounces--a day is the maximum.

Q: Why is fruit better than juice?

A: Juices are somewhat processed, so they lose the fiber and some of the vitamins and minerals that you get in fruit. We don't even know how to measure some of the constituents in real fruit. Also, a serving of juice has more calories than a piece of fruit, and we don't compensate for the calories in juices.

Vegetable juices like tomato juice have fewer calories and more nutrients than fruit juice, but they're high in sodium. So we recommended no more than a cup of any fruit or vegetable juice.

Q: Are sports drinks better than soft drinks?

A: Sports drinks are being increasingly pushed by the industry, and they have fewer calories than soft drinks. But they don't provide any real benefit, except for an endurance athlete. Nobody else needs the small amounts of hydration fluids--mostly water plus sodium, chloride, potassium, and sugars--they provide.

You need a very heavy sweat rate to need sports drinks. We're talking about marathoners. For people who are exercising for 15 to 20 minutes, sports drinks are irrelevant.

Q: What about alcoholic beverages?

A: You'll live if you have no alcohol, but light to moderate alcohol consumption--one drink a day for women and two a day for men--may lower risk of cardiovascular disease, diabetes, and gallstones.

We don't have rigorous evidence that red wine is better than white wine or beer or other drinks. Some studies show beneficial effects of red wine, but epidemiological evidence doesn't show a difference between alcoholic beverages.

Of course, excessive alcohol consumption causes serious health and social problems. It is associated with heart disease, several cancers, high blood pressure, as well as cirrhosis of the liver, to name a few. It is also linked to traffic and workplace accidents, spouse and child abuse, fires, falls, homicides, suicides, and other severe societal problems.

Q: And non-diet soft drinks have no benefits?

A: Zero benefits and major costs. Soft drinks and fruit drinks have contributed to a major increase in calorie intake in the last 20 or 30 years. The evidence isn't perfect that soft drinks will increase your weight or will lead to diabetes or dental caries, but it's pretty likely. Americans don't need them at all. We've got to cut down on our calories from fluids.

Q: Is the high-fructose corn syrup in soft drinks the problem?

A: It's too early to know. Right now we're concerned about all caloric sweeteners. A colleague, George Bray, and I wrote an article in which we speculated about potential harm from high-fructose corn syrup. But we really don't think this is a key issue. We must reduce soft drinks per se, no matter what the source of the sweetener.

Q: Should people drink non-diet soda at all?

A: None at all is the ideal pattern. If you have a 12-ounce serving of soft drinks or fruit drinks, you've got to compensate for the 160 calories you get from it.

We want people to halve the calories they get from beverages, from about 400 to 200 a day, which is only 10 percent of calories for the average person. [See "What We Should Drink," p. 5.] The ideal is to consume only what you need. For many, that's fat-free milk, and for others it might be some juice or alcohol.

Barry M. Popkin heads the Division of Nutrition Epidemiology in the School of Public Health at the University of North Carolina. He also directs the University's Interdisciplinary Center for Obesity. As a nutrition professor with a Ph.D. in economics, he has an unusual perspective on the factors that influence diet, exercise, and obesity. He spoke to Nutrition Action's Bonnie Liebman by phone from Chapel Hill.

The Beverage Guidance Panel, organized by Popkin and funded by the Unilever Health Institute in the Netherlands (Unilever owns Lipton Tea), included Lawrence Armstrong of the University of Connecticut Human Performance Laboratory in Storrs, George Bray of the Louisiana State University Medical Center in Baton Rouge, Benjamin Caballero of the Johns Hopkins University in Baltimore, Balz Frei of the Linus Pauling Institute and Oregon State University in Corvallis, and Walter Willett of the Harvard School of Public Health in Boston.

Fill 'er Up

                   Percentage of daily calories
                   (all Americans aged 2 and older)

                         1977-78   1999-2001

Coffee & Tea               0.8        0.9
Soft Drinks                2.8        7.0
Fruit Drinks               1.1        2.2
Alcohol                    1.6        3.5
Milk                       8.0        5.0
Other Milk Bevs.           0.5        0.3
Fruit Juice                1.7        2.0

We're drinking more. We got more of our calories from coffee and tea,
soft drinks, fruit drinks, alcohol, and fruit juice in 2001 than in the
late 1970s. Only calories from milk dropped during those 20 years.

Note: Table made from bar graph.

Source: Am. J. Prev Med. 27: 205, 2004.

What We Now Drink

Here's what the average American (aged 19 or older) reported drinking
in a 1999-2002 government survey. Of course, many people drink more (or
less) soda, coffee, milk, water, beer, etc.

Nevertheless, most of us would be better off getting fewer calories
from beverages, because liquid calories don't keep us from eating more
later. What's more, most of those calories come from beverages with no
nutrients (soft drinks and fruit drinks) or few nutrients (juices,
sports drinks, and alcoholic beverages).

Total: 14 cups--114 fluid ounces
(465 calories)

Soft drinks, fruit drinks                 2 1/2 servings (210 calories)
100% fruit juices, sports drinks,             2 servings (215 calories)
alcoholic beverages, whole or 2% milk
Diet drinks (1)                                1/2 serving (0 calories)
Milk, soy milk (2)                            1/3 serving (30 calories)
Unsweetened coffee or tea                      2 servings (10 calories)
Water                                           6 servings (0 calories)

(1) Includes diet soft drinks and tea or
coffee with sugar substitutes.

(2) Includes fat-free or 1% milk and
unsweetened fortified soy milk.

Adapted from Am. J Clin. Nutr. 83: 529, 2006.


What We Should Drink

This pitcher shows one way to follow the Beverage Guidance Panel's
advice (to right of pitcher) for someone who consumes 2,200 calories a
day. A serving is one cup (8 oz.), not a 12 oz. can of soda or a 12 oz.
"tall" latte. (Exception: a serving of beer is 12 oz., wine is 5 oz.,
and distilled spirits are 1 1/2 oz.)

An ideal diet would include no beverages other than water. But the
panel's advice was adjusted to accommodate our preferences (for sweets,
alcohol, caffeine, something to pour on our breakfast cereal, etc.) and
nutrient needs (for calcium, potassium, vitamin C, etc.).

The most important change is to eliminate regular soft drinks and fruit
drinks. Whole and 2% milk are missing because the panel recommended
none.

Panel's Advice

Total: 12 cups--98 fluid ounces
(200-300 calories)

Soft drinks, fruit drinks     0-1 serving (110 calories)
100% fruit juices,          0-1 serving * (115 calories)
sports drinks, alcoholic
beverages
Diet drinks (1)                0-4 servings (0 calories)
Milk, soy milk (2)           0-2 servings (100 calories)
Unsweetened coffee or tea      0-5 servings (0 calories)
Water                          2-6 servings (0 calories)

(1) Includes diet soft drinks and tea or
coffee with sugar substitutes.

(2) Includes fat-free or 1% milk and
unsweetened fortified soy milk.

* 0-2 servings of alcohol are okay
for men.

Adapted from Am. J. Clin. Nutr. 83: 529, 2006.

The Buzz

Coffee accounts for about 70 percent of the
caffeine we consume. Soft drinks make up about
15 percent, tea just over 10 percent, and chocolate
about 2 percent. Here are average caffeine
levels of popular beverages.

Beverage                                          Caffeine (milligrams)

Herbal tea (8 oz.)                                                    0
Starbucks Decaf Coffee, tall (12 oz.)                                10
Nestea Sweetened Lemon Iced Tea (16 oz.)                             20
Starbucks Decaf Coffee, venti (20 oz.)                               20
Green tea (8 oz.)                                                    30
Black tea (8 oz.)                                                    50
Coca-Cola (20 oz.)                                                   60
Dr. Pepper (20 oz.)                                                  70
Diet Coke (20 oz.)                                                   80
Red Bull (8 oz.)                                                     80
Starbucks Black or Green Tea, grande (16 oz.)                        80
Starbucks Caffe Latte or Cappuccino,
  tall (12 oz.)                                                      90
Starbucks Espresso, solo (1 oz.)                                     90
Coffee, filtered, drip (8 oz.)                                      100
Starbucks Coffee Frappuccino, tall (12 oz.)                         130
Starbucks Coffee Frappuccino, grande (16 oz.)                       170
Starbucks Caffe Latte or Cappuccino,
  grande (16 oz.)                                                   180
Starbucks Coffee Frappuccino, venti (24 oz.)                        260
Starbucks Caffe Latte or Cappuccino,
  venti (20 oz.)                                                    270
Starbucks Coffee, tall (12 oz.) 300
Starbucks Coffee, grande (16 oz.)                                   400
Starbucks Coffee, venti (20 oz.)                                    500

Sources: companies and U.S. Department of Agriculture.

Drink to Me Only

Beverage                                                Calories

Diet Coke (20 oz)                                              0
Water or Club soda                                             0
Coffee, with 1 liquid creamer (8 oz.)                         20
Tea, with 2 sugar packets (8 oz.)                             20
Coffee, with 1 liquid creamer and
  1 sugar packet (8 oz.)                                      30
Ocean Spray Light Cranberry Juice
  Cocktail (8 oz)                                             40
Tropicana Light or Minute Maid
  Light 'n Healthy Orange Juice (8 oz)                        50
V8 or tomato juice (115 oz.)                                  70
Milk, fat-free (8 oz.)  80
Yoplait Light Strawberry Smoothie (8 oz.)                     90
Milk, 1 % (8 oz.)                                            100
Silk Plain Soymilk (8 oz.)                                   100
Beer, light (12 oz.)                                         110
Orange juice (8 oz.)                                         110
Starbucks Coffee Frappuccino Light, tall (12 oz.) (2)        110
Apple juice (8 oz.) or Milk, 2% (8 oz.)                      120
Starbucks Caffe Latte, tall (12 oz) (2)                      120
Starbucks Cappuccino, tall (12 oz.) (2)                      120
Wine, white (5 oz.)                                          120
Gatorade (20 oz.)                                            130
Wine, red (5 oz.)                                            130
Cranberry juice cocktail (8 oz.)                             140
Silk Chocolate Soymilk (8 oz.)                               140
Grape juice (8 oz.)                                          150
Milk, whole (8 oz.)                                          150
Beer, regular (12 oz.)
Nestea Sweetened Lemon Iced
  Tea (16 oz.)                                               160
Dunkin' Donuts Coffee Coolatta
  with skim milk (16 oz.)                                    170
Gin and tonic, on the rocks (7 oz.)                          190
Starbucks Coffee Frappuccino,
  tall (12 oz.) (1)                                          190
Yoplait Strawberry Smoothie (8 oz.)                          190
Ginger ale (20 oz.)                                          200
Starbucks Cappuccino, venti (20 oz.) (3)                     210
Slim-Fast, canned (11 oz.)                                   220
Snapple Lemonade (16 oz.)                                    220
Coca-Cola or 7-Up (20 oz.)                                   250
Dannon Strawberry Blend Frusion
  (10 oz.)                                                   260
McDonald's Coca-Cola, large (32 oz.) *                       310
POM Wonderful 100% PomegranateJuice (16 oz.)                 320
Starbucks Caffe Latte, venti (20 oz.) (3)                    340
Dunkin' Donuts Coffee Coolatta
  with cream (16 oz.)                                        350
Starbucks Coffee Frappuccino,
  venti (24 oz.) (1)                                         350
Nestle Nesquik Chocolate Milk (16 oz.)                       400
7-Eleven Super Big Gulp, Coca-Cola
  (44 oz.) *                                                 410
TCBY Berry Slim Fruithead Smoothie
  (20 oz.)                                                   410
McDonald's Chocolate Triple Thick
  Shake, small (16 oz.)                                      580
Burger King Vanilla Shake, large (32 oz.)                    820
Baskin-Robbins Vanilla Shake,
  medium (24 oz.)                                            980
McDonald's Chocolate Triple Thick
  Shake, large (32 oz.)                                    1,160
Smoothie King Chocolate or
  Strawberry The Hulk (32 oz.)                             1,520

(1) Add 100 calories if you get it with whipped cream.

(2) Prepared using skim milk.

(3) Prepared using whole milk.

* Includes ice.

Sources: companies and U.S. Department of Agriculture.