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How Sweet It Is: Traditional Sweet Iced Tea and the Diabesity Epidemic.
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Natalie Taft MS, RDN, LDN, David N Collier PhD, MD, Robert Tanenberg MD, Kathryn M
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Kolasa PhD, RDN, LDN
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ABSTRACT
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In this paper we present four cases from our medical practice to increase awareness of the role of
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sweet tea in obesity and diabetes management. We start with a history of Southern style “sweet
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tea”, and discuss the importance of screening for beverage intake in the clinical setting. We note
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the associations between sugar sweetened beverage intake and weight that we often see in our
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clinics. Then we discuss resistance to changing a “sweet tea habit”. Finally, we sound an alert
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about the spread of sweet tea to other parts of the country. The cases we present are not atypical
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for clinical populations.
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INTRODUCTION
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This paper discusses the consumption of a specific sugar sweetened beverage (SSB) by adults
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and children known as sweet tea, iced tea, or often simply as “tea”. We encounter patients daily
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whose consumption of sweet tea contributes to their health risks. Studies have indicated a
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positive association between reported SSB consumption and weight gain and abdominal obesity
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(1-3). Others have demonstrated that reducing energy intake from SSBs results in weight loss
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(4-5). Furthermore a meta-analyses of prospective cohort studies demonstrates, that as the
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consumption of SSBs, including sweetened iced tea, has risen, this higher consumption of SSBs
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is associated with the development of metabolic syndrome and type 2 diabetes (3). Those who
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had the highest category of intake had 20% greater risk of developing metabolic syndrome and
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26% greater risk of type 2 diabetes, than those in the lowest category of intake.
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SSBs and overall energy intake.
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SSBs are the largest source of added sugars in the diet of U.S. youths. Data from 2005-2006
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NHANES survey showed for youth 2-18 years old, 11.1% of overall energy intake came from
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SSBs with 118 of the 173 kcal/day of SSBs coming from soda (6). SSBs contributed 45-50% of
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added sugars consumed (6). Data from the 2010 National Youth Physical Activity and Nutrition
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Study showed adolescents commonly consume water, milk or 100% fruit juice but additionally
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daily consumption of regular soda, sports drinks and other SSBs is common. Almost 15%
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reported daily consumption of coffee, coffee drink or any kind of tea (7). Consumers are
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beginning to hear the message that consuming soda and SSBs excessively is an unhealthy
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behavior. The 2014 Food and Health Survey documented consumers are more interested in the
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healthfulness of their beverages and are avoiding foods and drinks with added sugars (8). A
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2014 Gallup poll suggested that Americans are more likely to avoid drinking soda than before
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(9). Kit and coworkers (10) reported that between 1999 and 2010 the intake of SSB decreased
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by 68 kcal/day for youth and 45 kcal for adults, about 4 and 2.5 teaspoons of sugar respectively.
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Based on the literature, clinicians might assume that the usual consumption of SSBs, including
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tea, sweetened with sugar would total about 142 kcal/day or 8.8 teaspoons of sugar (2) and that
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the typical serving would have about 45 kcals. The cases we present will demonstrate a different
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reality for some patients presenting with health risks.
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Sweet tea, iced tea, “tea”.
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For this discussion, sweet tea, also known in the South as iced tea and “tea” is not a glass of cold
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tea that you add a packet of sugar or sweetener to, stir and drink. Traditional sweet tea, rather, is
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an icon of Southern culinary life. It is a drink of tea, ice and sugar. We routinely ask our patients
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how they prepare sweet tea and from those “recipes” calculate they consume from 60 to 230
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kcals/8 ounce serving. The typical recipe provides 100 kcals/8 ounces. Today’s typical tea glass
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holds 20 ounces or 150 to 575 calories/glass. Sweet tea is more than just mixing water, tea and
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sugar and adding ice, it’s saturating large quantities of tea with sugar (between 1 and 3 cups/half
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gallon). A syrup of sugar and water is made and then added to the brewed tea while it is still
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hot, then cooled and served over ice. Some prefer their tea to be “aged”—at least a day old,
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which is thought to enhance the sweetness. In fact, cane sugar or sucrose is a disaccharide
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comprised of glucose and fructose linked by an α-1, 2-glycosidic bond. Because fructose is
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sweeter than sucrose, hydrolysis of sucrose into glucose and fructose results in a sweeter product.
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There is no appreciable hydrolysis of sucrose at or below room temperature – however heating
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an aqueous solution of sucrose results in hydrolysis at the α-1,2-glycosidic bond. Hydrolysis is
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catalyzed by the addition of a small quantity of acid (lemon juice or cream of tartar). Hence
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heating a sucrose solution and/or adding lemon results in both a sweeter product and a product
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with much higher solubility at low temperatures as is the case in Southern iced tea.
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Sweet tea has long been sold in barbecue joints, fish camps and other restaurants serving “down
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home cooking”. In recent years fast food operations including national chains like McDonalds
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and Burger King have begun to sell sweet tea. In some locations, Starbucks sells an appealing
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shaken hand crafted tea. Grocery stores stock a wide variety of instant and ready-to-drink
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sweetened tea products. Our patients tell us they are brewing tea at home less often than in the
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past while bringing home as much as a gallon/day from a restaurant or store. Table 1 is a
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convenience sample of products named by patients and key informants or available in restaurants
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and grocery stores in North Carolina. The product information is from Nutrition Facts labels, if
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available. Sweet tea sold in restaurants ranges from 3.8 to 12.7 kcal/ounce, although it is not
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clear how many calories a consumer drinking a serving listed as “with ice” ingests. The ready-
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to-drink teas, often with added ingredients and promoted as healthy and upscale, range from 1.1
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to 13.8 kcal/ounce. Tea made following recipes provided by our patients ranges from 9.3 to 28.8
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kcal/ounce.
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from 8 to 11.4 kcal/ounce. The cases presented in this paper will demonstrate, the intake of
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SSBs, especially of sweet tea, for an individual patient may far exceed the estimates of SSB
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intake found in published surveys.
The generic value for sweet tea listed in on-line calorie tracking programs ranges
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We will now present a snap shot of the beverage consumption of three pediatric and one adult
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patient being treated for obesity and/or diabetes in our clinics. We will follow with a discussion
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of the history of sweet tea consumption in the South. This discussion informs the importance of
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screening for SSB intake and our use of the BEVQ-15 questionnaire (11-13) and our
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understanding of patients’ resistance to change a “sweet tea habit”. We highlight the
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associations between SSB intake and weight as a basis for our concern of the spread of sweet tea
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to other parts of the U.S. The cases we present are not atypical for clinical populations
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CASES
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I.C.: Severe obesity in a teen who doesn’t drink soda
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I.C. is an almost 15 year old African American female referred to our Comprehensive Pediatric
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Healthy Weight Clinic for evaluation for abnormal weight gain. She is seen by a physician and
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registered dietitian nutritionist (RDN). She presents with her mother who shares that she herself
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already has diabetes, knows what a hemoglobin A1C (HbA1c) value means and wants to prevent
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early diabetes in her daughter. I.C’s risk factors for diabetes/insulin resistance include her family
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history, sex, race, severe obesity (weight 256 lbs., Body Mass Index [BMI] 40.78 kg/m2 [99.4
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percentile for age and sex, BMI z-score = 2.52]), acanthosis nigricans on neck and axillae and a
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recent HbA1c of 6.1%. A fasting blood sugar of 101 mg/dL (<100 acceptable) and an insulin of
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39.4 uIU/ml (<24.9 acceptable) confirm insulin resistance; a total 25OH vitamin D of 7.1 ng/ml
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qualifies as vitamin D deficient and fasting triglycerides of 174 mg/dL (<90 acceptable; ≥130
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high) reveals isolated hypertriglyceridemia.
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I.C. is unable to state reasons that she would want to make changes in her drinks. She feels that
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she is active because she has band practice most days, preferring water or Gatorade. I.C.’s Mom
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describes her daughter as picky because she doesn’t eat much meat and often refuses what is
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offered for dinner. She also reports skipping breakfast because she is not hungry in the morning,
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and skipping lunch because does not like what the school serves. Two days a week she buys a
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chicken box, the school’s version of baked-not fried-chicken tenders, and a Gatorade. If she
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does not have band practice she will come home and have a HotPocket, chips or fruit and sweet
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tea or juice and nap until dinner. At least four times a week, they eat fast food because they like
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it and it is easy to buy nearby. When eating at home I.C. reports eating a big plate of noodles
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with meat sauce and salad with cucumbers, pineapple, egg, cheese and bacon bits with ranch
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dressing. Sweet tea is drunk with all dinners.
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The RDN administers and scores a beverage questionnaire (11), as a part of the initial visit, to
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determine how I.C’s. SSB intake affect her weight and health. I.C. brags that she doesn’t drink
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soda and that she recently started drinking water. Table 2 is I.C’s scorecard and shows that she
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is consuming 878 beverage kcal/day. Most of those calories, are from sweet tea and Gatorade,
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about 400 kcal/day (about 32 ounces) and 360 kcal/day (about 56 ounce), respectively. She
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purchases Gatorade at school to drink at band practice. I.C’s mom purchases sweet tea by the
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gallon from the McDonalds restaurant to drink at home. The RDN suggests that there are many
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changes in food and beverage choices that could be made to improve I.C.’s weight. The RDN
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reviewed a list of better and best beverage choices (14), plugging in lower calorie choices into
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the questionnaire to dramatically demonstrate the calorie savings with different beverage
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choices. They are both amazed at the difference in calories. However, I.C. is less motivated than
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her mother, not uncommon for youth to present in a different Stage of Change than their parent,
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so the behaviors chosen to target were under the control of the parent.
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JB: Teen with severe obesity and hypertriglyceridemia consuming 1,600 liquid kcal/day
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J.B., a 13-year old Caucasian male, and his younger sister were referred to our Comprehensive
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Pediatric Healthy Weight clinic for evaluation of abnormal weight gain. They were
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accompanied by their mother and grandmother who stated the reason for the visit was to “get
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help with our weight”. J.B. is 288 pounds and has been gaining weight at a rate of 0.6 lb. /wk.
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His Body Mass Index is 45.84 kg/m2, corresponding to the 99.8 percentile for age and sex (BMI
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z-score = 2.83). His initial fasting lab evaluation revealed hyperinsulinemia (31.7 uIU/ml ;
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normal <24.9), vitamin D deficiency (18.0 ng/ml; < 20 is deficient), elevated transaminases with
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an AST of 45 IU/L (≤ 40 normal) and an ALT of 59 IU/L (≤30 normal) and isolated elevated
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triglycerides of 238 mg/dL (< 90 acceptable; ≥130 high). J.B. hints he is physically limited by
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his size. His mother is concerned that J.B. does “not eat the healthy stuff” when she buys it but
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“eats snacks until they are all gone”. J.B. says he wants “to eat more fruits and vegetables and
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try not to eat as much at one time”. J.B.’s younger sister’s BMI, 36.8 kg/m2, corresponding to the
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99 percentile for age and sex, but she has maintained weight since the visit with her pediatrician.
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Mom shares that at 255 pounds (BMI > 45 kg/m2) she weighs more than she ever has. They
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agree that they all can benefit from lifestyle change. They acknowledge they are very set in their
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ways and granddaddy, who lives with them, doesn’t like changes in his foods or drinks.
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A 24-hr dietary recall documents that J.B.’s intake includes multiple ready-to-eat snacks and
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sweets that are appealing and readily available. While there are many changes that J.B. could
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make to his food intake, his beverage intake is the focus of our attention. A completed beverage
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questionnaire (11) quantified his total beverage intake as 1600 kcal/day with 700 kcal from
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beverages with sugar as the primary sweetener and 900 kcal/day from whole milk. Sweet tea
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was the source of 600 kcal (about 50 ounces) and soda of 100 kcal (8 ounces). J.B. chooses
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sweet tea with his meals, drinking from his 20-oz Carolina Mudcats baseball cup. JB’s mother
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and grandmother brew their tea the “way we always have” by adding 1 ½ to 2 cups of
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sugar/gallon, although they said they used to use even more sugar. The Drink Scorecard, the
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risks of hypertriglyceridemia, J.B.’s lab results and the benefits of reducing his intake of added
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sugars were explained to the family. J.B. said he could not resist sweet tea if it was available.
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Using the beverage questionnaire the RDN demonstrated J.B. could cut 480 kcal/day if he would
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limit tea to dinner time. Together they estimated that this change could lead to a 1 lb. /wk weight
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loss and improvement in his Triglycerides. J.B’s sister, on the recommendation of their
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pediatrician had already stopped drinking tea and changed to sugar free drinks and water and she
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encouraged her brother.
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J.L.C.: Weight trajectory in a severely obese 13 year old who struggles to control his sweet tea
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consumption.
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J. L.C. Is a Hispanic male who originally presented to the Comprehensive Pediatric Healthy
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Weight Clinic for evaluation of abnormal weight gain about three years ago. At that time he was
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almost 11 years old, with a height of 63.7 inches , weight of 201 lbs. and a BMI of 34.85 kg/m2
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(> 99th percentile for age and sex, BMI z-score = 2.57). Fasting blood work at that time was
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significant for low HDL (19 mg/dL, >40 is desirable) and hypertriglyceridemia (triglycerides
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170 mg/dL, < 90 acceptable; ≥130 high). He was lost to follow-up for 17 months, but returned
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and has had 12 visits over the past 20 months. Several factors including sedentary lifestyle,
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excessive portions, poor diet quality and consumption of 2-3 gallons of sweet tea daily have
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prevented J.L.C. from meeting his goal of weight loss. At his 8th visit (after 31 months in
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treatment) J.L.C. and his mom agree that excessive sweet-tea consumption is a significant
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behavior that they will consider improving. This agreement was precipitated in part by his
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mother, who has 2 diabetes and was drinking 1-2 gallons of sweetened tea/day herself, learned
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that her HbA1c was 12%. Although addressed at each visit, it took until visit 8 before they
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would set as goals to 1) use only ¼ cup sugar per gallon (194 kcal/gal); and 2) try and reduce
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J.L.C.’s consumption from 3 to 1 gal/day. Table 3 below summarizes his BMI, weight and rate
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of weight change at visit 9 through 13, provides an estimate of his theoretical daily energy
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balance as well as the daily caloric contribution made by his tea consumption. An estimate of
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daily positive energy balance is based on the assumption that a net positive energy balance of
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500 kcal/day results in one lb. /wk weight gain. As can be seen, J.L.C.’s daily calories from tea
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closely match the theoretical excess daily calories associated with the variable rate of interval
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weight gain.
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Mr. J: an Adult Patient with Uncontrolled Diabetes. Mr. J, a 60 year old white male was new to
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our clinic and presented with uncontrolled type 2 diabetes mellitus and a history of gout,
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hyperlipidemia, hypertension and obesity. His primary care physician who has managed his
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diabetes for the last 30 years had retired. Mr. J. does not recall ever receiving diabetes education
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or meeting with a RDN. Mr. J. acknowledged that he has had a sedentary lifestyle and eats most
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of his meals at local restaurants. The only beverage he drinks is sweet tea. His BMI is 34.11 and
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his HbA1c was 12.5% today (normal < 5.7%). His medications include long-acting insulin
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glargine (Lantus®, Sanofi-Aventis) and short-acting insulin aspart (Novo Log® Norvo Nordisk)
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employing a multiple dose injection (MDI) regime. He reports checking finger stick blood sugars
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four times a day. In recalling his usual dietary intake, he would not quantify the amount of sweet
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tea he drank only saying it was several glasses/day, pointing to the 16 ounce model as his typical
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glass. The RDN assigned the nutritional diagnosis as: “Knowledge/Beliefs: Nutritional
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knowledge deficit related to diabetes self-management as evidenced by food/beverage summary,
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sedentary lifestyle, and HbA1c” and discussed several strategies for improved blood sugar
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control including avoiding sweet drinks, increasing physical activity, taking his medicines as
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prescribed, avoiding fast food and preparing more meals at home following "plate method" for
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appropriate portion control. He was reluctant to make a SMART goal—one that is specific,
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measurable, achievable, realistic and timely (15) during this visit. On a scale of 0-10, he rated
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his confidence in being able to make any change as in his tea consumption as “0”. He agreed to
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follow up in 2 months.
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BACKGROUND
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Sweet Tea.
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The history. The history of this southern style sweet tea is unclear (16). Stradley (17) chronicles
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a history of tea coming from South Carolina, the only state in the U.S. to have commercially
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grown tea and says sweet tea’s popularity rose along with refrigeration. She also notes that “In
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the South, iced tea is not just a summertime drink, it is served year round with most meals”.
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Holly Mathews (18), a professor of anthropology at East Carolina University told us there are no
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definitive writings about sweet tea’s history but guessed that Southerners were closely aligned to
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Britain during the early years of the nation and tea was a popular import. Southerners, too, had a
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steady supply of sugar from Caribbean plantations. Colonial southern elites were in the habit of
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drinking large quantities of alcohol and there were many recipes mid-18th century that combined
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tea, sugar and alcohol. Prohibition removed the alcohol (19) and with the widespread
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electrification of the rural south in the 1930s and 40s along with the delivery of ice, drinking
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sweet tea became popular.
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Today, Southern style sweet tea is served at time honored events called pig pickin’ barbecues
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along with pig, baked beans, Cole slaw and hush puppies. Barbecues are important features of
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church functions, political rallies and celebrations. Local restaurants have fierce sweet tea
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competitions during festivals. Waitressed pour gallons and gallons of sweet tea into bottomless
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16 ounce Styrofoam cups throughout the day at diners and fish camps. Boy scouts take jugs of
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Aunt Berties Concentrated Brewed tea on their camping trips. In one popular reality TV show,
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the story is told that Duck Commander Si Robertson while in the Army received a tea glass from
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his mom. The glass, filled with sweet tea, has been in his hand or back pocket ever since. A 16
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ounce glass, just like the Si’s is available for purchase on the Web for less than $10.
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“Our StateR North Carolina” magazine periodically publishes articles about the food that defines
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“southern”. During summer 2014 it posted a food quiz for readers to find out “What classic
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Southern Food are you? (20) “Sweet tea”, described as “the epitome of Southern hospitality” was
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one of the personalities. The “Sweet tea” personality reportedly makes “whoever’s around you
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happy”. The portrayal ends with “What’s not to love?” The other food personalities were
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pimiento cheese, peanuts, biscuit, banana pudding, fried chicken and scuppernong grape. From
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time to time, this magazine includes a feature or recipe about tea. The August 2010 cover
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highlighted “Southern Roots”. It described sweet tea, the banjo, and red clay, front porches and
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longleaf pines” as symbols long associated with the South. In the feature essay sweet tea is
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described as “our alchemy—our gift of making something special from humble ingredients”
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(19).
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Who drinks Southern Style Sweet tea? It’s hard to know. We were unable to find a data base
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that documents the intake of southern style sweet tea. Dr. Stephen Onufrak, a beverage data
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expert at the Centers for Disease Control (CDC) told us that “sweet tea” intake is not often
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reported in papers investigating SSB intake (21). Dr. Kit, also at CDC, noted that studies like
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NHANES include an item documenting “coffee or tea sweetened with sugar” intake but agreed it
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may not capture the high the intake of “southern style sweet tea consumption” (22). Researchers
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developing a regionally appropriate food frequency questionnaire for the Lower Mississippi
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Delta Region found sweet tea to be a significant contributor of energy (1.9%, rank 12 of food
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groups studied) and of carbohydrate intake (4.1% rank 3) for white adults (22). For those
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consuming sweet tea, the median portion size was 474 grams or 14.6 ounces; with 858 grams or
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26.5 ounces at the 85th percentile (23). The Delta NIRI FQ (Tucker) for adults assumes “very
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sweet tea” to be a recipe of 1 cup sugar/1 gallon of tea, much lower than the 1-3 cups sugar/half
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gallon reported by our patients.
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There are no definitive writings about sweet tea’s history Unable to find literature to tell us who
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drinks Southern Style sweet tea, we used the power of electronic mailing lists and FACEBOOK,
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to find out if there is a “sweet tea belt?” We heard from nutrition educators, many employed by
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the Cooperative Extension Service, clinical and community RDNs from 21 states, and friends
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and family from the Southeast. We then pieced together the map of states where informants told
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us if you ordered “tea”, you would be served iced sweet tea (Figure1) and it looked similar to
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the 11 state region consisting of Alabaman, Arkansas, Georgia, Indiana, Kentucky, Louisiana,
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Mississippi, North Carolina, South Carolina, Tennessee and Virginia—often referred to as the
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stroke belt or stroke alley. We noted on the map states where our informants told us drinking
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sweet tea is a new phenomenon—primarily linked to its availability in chain restaurants. We
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received the response, “I never heard of the specific drink called sweet tea until McDonalds
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started selling it with that name” from many respondents.
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side of a bus for iced sweet tea at McDonalds—in Chinese. It appears that residents in the
One Californian noticed an ad on the
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southeastern U.S. have a long standing tradition of drinking sweet tea and the behavior appears
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to be spreading throughout the U.S.
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BEVQ: A Tool to Screen for Beverage Intake.
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Many clinicians use a brief nutrition history taking tool known as the “WAVE” Assessment (24).
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The “E” in WAVE stands for “Excess” and clinicians, aware of the general food habits of the
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patients in their practice, asks questions about foods and beverages typically consumed in excess.
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If the clinician wasn’t aware of sweet tea, he/she might just ask about sodas or other SSBs to
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obtain a general impression of intake. The Beverage Intake Questionnaire (BEVQ) is a
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quantitative food frequency questionnaire developed, shortened and validated in adults to assess
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habitual beverage consumption in the past month (11-12). It requires only 2 minutes for an adult
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to complete (11). We find a version (BEVQ-15) without alcohol is clinically useful with youth
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as an assessment and counseling tool even though it has not yet been validated (11, 13, 25). Our
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interactive Drink Scorecard based on the BEVQ-15 (Table 2) uses 10 kcal/ounce as the average
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for sweet tea consumed by our patients.
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Efficacy of interventions to reduce SSBs in obese youth and adults
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Reducing intake of SSBs. Most experts agree there is sufficient evidence to adopt public health
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strategies to discourage the consumption of sugary drinks as part of a healthy lifestyle. The
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available data show a positive association between greater intakes of SSBs and weight gain and
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obesity in both children and adults (2-3). In our experience, in spite of limited published
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evidence, when our obese youth and adult patients reduce their intake of SSBs they experience
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weight loss and improved glucose control. Data from the PREMIER trial support the strategy of
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limiting liquid calorie intake among adults (4). Participants in the study had a mean intake of
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356 kcal/day liquid calories with 131.1 kcal/day coming from SSB (only 46.5 kcal from coffee
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or tea, sweetened with sugar). A reduction of 1 serving of SSB/day was associated with a weight
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loss of 0.49 kg at 6 months and 0.65 kg at 18 months. The consumption of diet drinks did
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increase. They further noted that reduction of liquid calories had a stronger effect on weight loss
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than reducing solid calories (4).
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For youth, too, in a yearlong school based study, a modest reduction in the number of carbonated
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drinks consumed led to a significant reduction in the prevalence of overweight and obesity (26).
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In a 25-week pilot study, adolescents reduced their intake of SSBs substituting water, no and/or
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low calorie beverages with a beneficial effect on body weight (27).
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5-2-1-0 every day or 5-3-2-1-almost none?
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The Maine “Keep ME Healthy” program coined the “5-2-1-0” message that called for restricting
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sodas, and sugar sweetened sports and fruit drinks. North Carolina clinicians were skeptical
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about the potential response from patients to a zero SSBs message and not finding evidence to
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support that approach adopted an “almost none” message (28). Table 4 lists the beverage
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recommendations for youth at elevated cardiovascular risk, including those who are obese (29).
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Unfortunately they provide no guidance about use of non-nutritive sweeteners. Subsequently
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studies have shown that some adults who replaced SSBs with diet beverages as a method of
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weight loss had greater losses than those who replaced with water (5, 30, 31).
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Resistance to change
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Cultural tradition. One respondent to our informal survey said, “Sweet tea is an integral part of
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growing up in the south—it’s like oxygen. “You drink it to live... you drink it to survive… you
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are never without sweet tea”.” Our patients tell us that in their homes sweet tea is ALWAYS
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available—year round. It is always served to friends. Some report that it is the only beverage
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available in their home and used “even to moisten cornflakes”. Many respondents reported they
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grew up drinking sweet tea instead of milk. Some said they didn’t use a recipe but would know
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the tea was sweet enough “when you can feel the sugar on your teeth.” More than one survey
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respondent said that being told by a physician or RDN to stop drinking sweet tea would be “a
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fate as bad as death.” Perhaps Tomlinson (19) captured the tradition best with these words,
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“Sweet tea is homemade. And it’s part of how you make your home”. Even so, change is
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occurring among sweet tea lovers. Some are using less sugar/gallon or using half sugar and half
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non-caloric sweetener. Some retain the original family recipe but serve it only on weekends or
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special holidays. At restaurants, some order their tea half sweet mixed with half unsweetened.
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Some may actually benefit from switching from home brewed to restaurant or ready-to-drink
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products that are lower in kcals. One informant summed up her sentiments in this way: “I
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understand the importance of limiting sweetened beverages, but every once in a while—on a hot
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summer day—I can’t resist drinking full strength sweet tea.”
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Environmental influences on consumption. Clinicians seeking strategies to overcome resistance
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to change might draw on the emerging literature on environmental influences choices. The
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importance of dishware and beverage container size to consumption has been demonstrated (32-
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33). Applying the results of research on effects of sports organizations and players and branding
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and licensing characters on attitudes of children to support behavior change may be effective
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(34-36).
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“Food Addiction “and/or Reward? Perhaps there is more than culture and tradition and work.
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Some of our patients declare that they are “addicted” to sweet tea”. One patient who consumes a
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gallon/day says she knows “it’s not good for me, but I love it and I have to have it.” In our
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medical center new devotees to sweet tea “are born” every year, even among those northern
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transplants who gag on their first sip of tea served at a welcome luncheon. It is not unusual for
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some of our medical students or house staff to find the gain 5 to 10 pounds during their first year
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-- attributable to frequent consumption of sweet tea.
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concept of a sugar based food addiction researchers are exploring ways humans react to food.
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Hebebrand and coworkers postulate that people can have a behavioral addiction to eating for its
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own sake but there is no strong evidence they are addicted (37). The work of Stice and
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coworkers (38) implies, that consuming sugar can activate reward, gustatory, and somatosensory
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regions of the brain. They state their results imply that sugar more effectively recruits reward and
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gustatory regions than fat, suggesting that policy, prevention, and treatment interventions should
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prioritize reductions in sugar intake.
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Although there are few data to support the
CASES REVISTED
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In all four cases the caloric intake from sweet tea was much higher than the 150 kcal/day
357
documented in the literature we reviewed but upwards to 600 kcal/day. Since these are empty
358
calories helping patients choose to reduce their consumption of sweet tea for weight loss or
359
maintenance and for improved glycemic control is often the first life style change we encourage.
360
361
I.C.: Teen who doesn’t drink soda
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I.C. is an example of a teen who drinks no soda but consumes a significant number of kcals from
363
other SSBs. We used the BEVQ-15 (11) and Drink Scorecard to both document intake and to
364
negotiate goals. I.C.’s mom was in the Action Stage and set as a goal to eat fast food less often
17
365
and avoid purchasing sweet tea to take home. I.C. loves water and so by making the sweet tea
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less available it was easy for her to choose water for her meal beverage. Mom did purchase
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some sugar free drinks as sweet tasting alternative for the times I.C. wanted something “sweet”.
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I.C. presented at her 1 month follow-up visit with a 1.6 pound weight loss, consistent with 200
369
kcal/day deficit, reporting fewer fast food meals, fewer glasses of tea and a switch to a reduced
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sugar sports drink. Her HbA1c was lower at 5.7%. All agree that the behavior change around
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sweet tea and sports drinks was responsible for these improvements. Even if patients declare
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they drink no soda, it is important to recognize other beverages may contribute more calories
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than the 140 calories in a 12 ounce cola including some drinks with up to 270 calories per
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container like sodas, tea ,Frappuccino’s, smoothies, lemon aid, Coolattas, energy drinks and low
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fat chocolate milk (39).
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J. B. Teen with abnormal weight gain
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On leaving clinic, J.B.’s grandmother stopped at the bookstore and purchased a 12 ounce ECU
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Pirate tumbler to replace the 20 ounce MUDCAT cup. She also shared the Drink Scorecard and
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information about J.B.’s health with granddaddy. He agreed to try tea made with less sugar but
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reminded them that he didn’t like the taste of any “fake sweetener”. J.B.’s case reminds us that
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screening for all beverages in a systematic way takes little time and provides better data than a
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24 hour diet recall. Patients and family can easily see that even occasional consumption of
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energy dense drinks in large quantities can provide significant kcals. The Drink Scorecard report
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also is useful as an accountability tool.
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J.L.C. A 14 y.o. with severe obesity who struggles to reduce sweet tea consumption.
18
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J.L.C. tries to reduce his sweet tea consumption because he can see the difference it makes in his
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weight gain (Table 3). Even so, he rarely drinks less than one gallon per day. He is unwilling to
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drink unsweetened tea and his family believes they cannot afford other sweeteners. The medical
389
team did provide him a trial of a sugar/stevia blend that he found “sort of acceptable”. J.L.C.
390
also quotes a TV commercial “iced tea gives dinner the flavor the Muppets savor” (40)—water
391
has no flavor he feels that “water has no flavor”. He is adherent to his appointment schedule but
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unable to control his sweet tea consumption.
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Mr. J: Adult patient with uncontrolled diabetes
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Mr. J was reluctant to agree to eliminate sweet tea from his life having drunk it every day of his
395
life with most meals. He loved his mother’s tea. His previous doctor had never told him it was
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bad for his diabetes to drink sweet tea. Although he was not confident that he could discontinue
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all SBB he said “I will try but I hate the after taste of diet drinks and don’t like water”. On follow
398
up his blood glucose records showed marked improvement in glycemic control. He said he found
399
helpful the information the RDN provided about the features of low calorie sweeteners including
400
that they had no impact on short or long term blood sugar levels or insulin; were non cariogenic;
401
and using them could lead to consuming less added sugar, carbohydrates and calories. He found
402
a low carbohydrate sweetener made from monk fruit tasted good in his tea. He also learned the
403
waitress kept a pitcher of unsweet tea at the restaurant for those who requested it. For patients
404
like Mr. J, slowly modifying his sweet tea with the use of low-calorie sweeteners can yield
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clinically important benefits for his glucose and weight management. His HbA1c had fallen
406
from 10.5% to 8.5% and he lost 5 lbs. His finger stick blood glucose values were between 110-
407
140 mg/dl. We expect his HbA1c to continue to fall another 1/2% over the next month. This
19
408
case demonstrates that changing excessive SSB behaviors can be more potent than most of the
409
drugs used to treat type 2 diabetes.
410
A Final Word
411
412
A Final Word
413
Sweet Tea is going nation-wide
414
We stated that one of our objectives was to raise awareness about sweet tea. We are concerned
415
about the spread of the practice of drinking sweet tea. We found in our informal survey that
416
adults and children outside the “sweet tea belt” are being introduced to sweet tea at fast food and
417
fast casual restaurants. McDonalds and McAlister’s Deli were specifically mentioned as places
418
where consumers have recently had their first taste of sweet tea. McAlister’s Deli, with 320
419
restaurants in 24 states, sells a 32 ounce sweet tea with ice-- 120 calories, 32 grams of carb—all
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from added sugar. They have announced major expansion plans (41). We have observed bumper
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stickers affixed to the back of the children’s booster chairs in their outlets that read “put some of
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that sweet tea in my sippee cup”.
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Soda and Sugar are Bad. Is Tea Good?
424
A recent Gallup poll concluded that since 2002, soda and sugar have become foods that
425
Americans consider bad for them (9). In 2014, almost two-thirds (63%) of Americans say they
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try to avoid drinking soda and 52% avoid sugar. We don’t know if the avoidance sentiment
427
translates to sweet tea. In his introduction to the fifth international symposium on tea and human
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health, Blumberg (41) noted that numerous research studies suggest that regular consumption of
20
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tea is associated with an array of health benefits, including impacts on chronic conditions such as
430
cancer, diabetes, heart disease, neurodegenerative diseases, and obesity. Consumers hear these
431
messages in advertisements, on website and in magazine articles about tea perhaps giving tea a
432
health “halo”. It is important for health care professionals to encourage their patients and
433
consumers to read the Nutrition Facts labels on food and beverage products and monitor their
434
intake of all caloric beverages.
435
436
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ACKNOWLEDGEMENTS
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We thank Teisha Lightbourne, Master of Public Health in Nutrition candidate at the UNC
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Gillings School of Global Public Health for the research into and preparation of Table 1; Paula
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Munos, Brody School of Medicine for preparation of Figure 1;Kelli Davenport RDN, LDN,
544
Brody School of Medicine for discussion of the adult case; Kay Craven MPH, RDN, LDN, CDE,
545
Brody School of Medicine; Ms. Gina Firnhaber MSN, MLS, MPH and Ms. Kathy Cable Laupus
546
MLS, Health Sciences Library, and Dr. Carolyn Lackey, Professor Emeritus, NC Cooperative
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Extension Service, North Carolina State University for the assistance in surveys, literature
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search and preparation of the manuscript.
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26
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Table 1. Sugar Sweetened Sweet Tea Beverages
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Table 2. I.C.’s Drink Scorecard
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Table 3. J.L.C’s BMI, weight, rate of weight gain, calories from tea
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Table 4. Cardiovascular Health Integrative Lifestyles Diets (CHILD) and Recommendations
554
relevant to beverage intake
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Figure 1. “Sweet Tea Belt”