Title: Does Consumption of Cola Beverages Cause Bone Fractures in Children?
Abstract: To the editor: I read with interest the informative and thorough review by Dr Fitzpatrick1Fitzpatrick LA Secondary causes of osteoporosis.Mayo Clin Proc. 2002; 77: 453-468PubMed Scopus (206) Google Scholar on secondary causes of osteoporosis. An additional possible cause of bone mineralization reduction and fractures in children is the consumption of cola beverages. Drinking cola beverages, which contain phosphoric acid and often caffeine, may increase the fragility of bones in children and adolescents through interactions with the bone mineral content2Wyshak G Frisch RE Carbonated beverages, dietary calcium, the dietary calcium/phosphorus ratio, and bone fractures in girls and boys.J Adolesc Health. 1994; 15: 210-215Abstract Full Text PDF PubMed Scopus (166) Google Scholar and has been found by several investigators to be associated with an increased risk of bone fractures. Consumption of cola beverages was positively associated with bone fractures in girls in 9th and 10th grade,3Wyshak G Teenaged girls, carbonated beverage consumption, and bone fractures.Arch Pediatr Adolesc Med. 2000; 154: 610-613Crossref PubMed Scopus (220) Google Scholar in girls aged 8 to 16 years,2Wyshak G Frisch RE Carbonated beverages, dietary calcium, the dietary calcium/phosphorus ratio, and bone fractures in girls and boys.J Adolesc Health. 1994; 15: 210-215Abstract Full Text PDF PubMed Scopus (166) Google Scholar and in children aged 7 to 14 years.4Petridou E Karpathios T Dessypris N Simou E Trichopoulos D The role of dairy products and non alcoholic beverages in bone fractures among schoolage children.Scand J Soc Med. 1997; 25: 119-125PubMed Google Scholar The amount of cola beverages involved is minimal: consumption of 0.7 or more cans or bottles of cola beverages per day resulted in a statistically significant increase in bone fractures in girls younger than 17 years.2Wyshak G Frisch RE Carbonated beverages, dietary calcium, the dietary calcium/phosphorus ratio, and bone fractures in girls and boys.J Adolesc Health. 1994; 15: 210-215Abstract Full Text PDF PubMed Scopus (166) Google Scholar Noncola carbonated soft drinks, however, do not contain phosphoric acid and often do not contain caffeine, and several studies have found that noncolas are not specifically associated with increased fracture risk among school-aged children.2Wyshak G Frisch RE Carbonated beverages, dietary calcium, the dietary calcium/phosphorus ratio, and bone fractures in girls and boys.J Adolesc Health. 1994; 15: 210-215Abstract Full Text PDF PubMed Scopus (166) Google Scholar, 3Wyshak G Teenaged girls, carbonated beverage consumption, and bone fractures.Arch Pediatr Adolesc Med. 2000; 154: 610-613Crossref PubMed Scopus (220) Google Scholar, 4Petridou E Karpathios T Dessypris N Simou E Trichopoulos D The role of dairy products and non alcoholic beverages in bone fractures among schoolage children.Scand J Soc Med. 1997; 25: 119-125PubMed Google Scholar In a study of 460 teenaged girls, Wyshak3Wyshak G Teenaged girls, carbonated beverage consumption, and bone fractures.Arch Pediatr Adolesc Med. 2000; 154: 610-613Crossref PubMed Scopus (220) Google Scholar showed an increased risk of bone fractures in active girls who drank colas but not noncolas; conversely, there was no increased risk of fractures in active girls who drank noncolas but not colas. However, active girls who drank both colas and noncolas had an increased risk of fractures. Phosphoric acid is associated with altered calcium homeostasis and development of hypocalcemia.5Guerrero-Romero F Rodriguez-Moran M Reyes E Consumption of soft drinks with phosphoric acid as a risk factor for the development of hypocalcemia in postmenopausal women.J Clin Epidemiol. 1999; 52: 1007-1010Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar, 6Mazariegos-Ramos E Guerrero-Romero F Rodriguez-Moran M Lazcano-Burciaga G Paniagua R Amato D Consumption of soft drinks with phosphoric acid as a risk factor for the development of hypocalcemia in children: a case-control study.J Pediatr. 1995; 126: 940-942Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Consumption of approximately 0.6 or more cans or bottles of cola beverages per day is a risk factor for the development of hypocalcemia in children 14 years of age or younger.6Mazariegos-Ramos E Guerrero-Romero F Rodriguez-Moran M Lazcano-Burciaga G Paniagua R Amato D Consumption of soft drinks with phosphoric acid as a risk factor for the development of hypocalcemia in children: a case-control study.J Pediatr. 1995; 126: 940-942Abstract Full Text Full Text PDF PubMed Scopus (55) Google Scholar Similarly, the consumption of 1 or more bottles of cola beverages per day is associated with hypocalcemia in postmenopausal women.5Guerrero-Romero F Rodriguez-Moran M Reyes E Consumption of soft drinks with phosphoric acid as a risk factor for the development of hypocalcemia in postmenopausal women.J Clin Epidemiol. 1999; 52: 1007-1010Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar GarciaContreras et al7Garcia-Contreras F Paniagua R Avila-Diaz M et al.Cola beverage consumption induces bone mineralization reduction in ovariectomized rats.Arch Med Res. 2000; 31: 360-365Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar showed that rats that drank cola beverages developed hypocalcemia and lower femoral mineral density compared with control rats that drank water. Caffeine is also present in most cola beverages and may affect bone health. Ohta et al8Ohta M Cheuk G Thomas KA et al.Effects of caffeine on the bones of aged, ovariectomized rats.Ann Nutr Metab. 1999; 43: 52-59Crossref PubMed Scopus (17) Google Scholar showed that caffeine intake affected the content and crystallite size of bone minerals and that the femurs of rats fed caffeine tended to be weaker compared with controls. Wyshak and Frisch2Wyshak G Frisch RE Carbonated beverages, dietary calcium, the dietary calcium/phosphorus ratio, and bone fractures in girls and boys.J Adolesc Health. 1994; 15: 210-215Abstract Full Text PDF PubMed Scopus (166) Google Scholar found no association, however, between total caffeine intake and the risk of fractures among girls or boys. Maximizing peak bone mass during childhood and adolescence may be important in preventing osteoporosis.9Heaney RP Matkovic V Inadequate peak bone mass.in: Riggs BL Melton III, LJ Osteoporosis: Etiology, Diagnosis, and Management. 2nd ed. Lippincott-Raven Publishers, Philadelphia, Pa1995: 115-131Google Scholar Although noncolas have not specifically been associated with increased fracture risk among school-aged children, replacing milk in the diet with soft drinks of any type may interfere with the attainment of maximum peak bone mass in adolescents and young adults. Consumption of soft drinks increased dramatically from 1965 to 1996 among US children and adolescents, whereas milk consumption decreased.10Cavadini C Siega-Riz AM Popkin BM US adolescent food intake trends from 1965 to 1996.Arch Dis Child. 2000; 83: 18-24Crossref PubMed Scopus (310) Google Scholar Harnack et al11Harnack L Stang J Story M Soft drink consumption among US children and adolescents: nutritional consequences.J Am Diet Assoc. 1999; 99: 436-441Abstract Full Text Full Text PDF PubMed Scopus (582) Google Scholar found that soft drink consumption was inversely associated with consumption of milk in children and adolescents. Whiting et al12Whiting SJ Healey A Psiuk S Mirwald R Kowalski K Bailey DA Relationship between carbonated and other low nutrient dense beverages and bone mineral content of adolescents.Nutr Res. 2001; 21: 1107-1115Abstract Full Text Full Text PDF Scopus (74) Google Scholar showed that replacing milk in the diet with carbonated and other low-nutrient-dense beverages was negatively related to total body bone mineral content in girls at the time of peak bone mass accrual (mean age, 12.5 years for girls; range, 10.5-14.6 years13Bailey DA Martin AD McKay HA Whiting S Mirwald R Calcium accretion in girls and boys during puberty: a longitudinal analysis.J Bone Miner Res. 2000; 15: 2245-2250Crossref PubMed Scopus (325) Google Scholar). The adverse effect of carbonated soft drinks on bone health, whether by possible phosphoric acid- and caffeine- related mechanisms in colas or by replacement of calcium-rich milk with soft drinks of any type, is of substantial public health concern, particularly for girls and women because of their proneness to osteoporosis in later life.2Wyshak G Frisch RE Carbonated beverages, dietary calcium, the dietary calcium/phosphorus ratio, and bone fractures in girls and boys.J Adolesc Health. 1994; 15: 210-215Abstract Full Text PDF PubMed Scopus (166) Google Scholar Even more troubling is that no current pharmacological treatment is able to completely revert the damages caused to bone mass and bone architecture.14Ben Sedrine W Reginster J-Y Risk indices and osteoporosis screening: scope and limits [editorial].Mayo Clin Proc. 2002; 77: 622-623Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Does Consumption of Cola Beverages Cause Bone Fractures in Children?–Reply–IMayo Clinic ProceedingsVol. 77Issue 9PreviewIn reply: I appreciate the thoughtful letter by Dr Kinney regarding the issues of phosphoric acid and bone loss. In the past, this area of bone metabolism has been confounded by multiple studies with differing results, but several panels of experts addressed this issue recently. Full-Text PDF