A follow up on problems real and imagined with sugar soda. The news story that Coca Cola was the primary factor in the death of a 30 year old mother immediately attracted my attention. It has been widely reported on the internet and specifically on ABC News that a coroner in New Zealand has causally linked Coca Cola with her death. Like most science news stories, the story is short on facts and long on hype. What caught my attention about this story is the link to Coca-Cola specifically. There have been claims that she had children born without dental enamel, and that she had a toxic level of caffeine. After reviewing what is known, her death is a little more complicated and much less sinister than presented by the news media.
The corner’s statements, and the multinational Corporation Coca-Cola is of course a compelling narrative. It makes for good press and catchy headlines. I have no doubt that her Coca-Cola intake had a direct causal effect on her death. The fact that the liquid she consumed was the soft drink Coca-Cola is irrelevant. In my opinion, what is critical about this case is the woman’s behavior and resulting medical issues related to that. Despite media allusion that her children are being born without dental enamel, or that is somehow causally related to Coca-Cola, that is not the case. There is nothing specific about Coca-Cola as a beverage that would result in lack of dental enamel in unborn children. When I reviewed this case I see overwhelming evidence that the inconsequential facts of the case have been exaggerated, and the key factors have been minimized. This results in a deceptive discussion about the toxic effects of Coca-Cola. In fact it is not the substance that is toxic, it is the volume.
Lets begin with the facts as presented in the media. “A New Zealand coroner has linked the death of a 31-year-old woman to her Coca-Cola addiction.Natasha Harris died Feb. 25, 2010 from a cardiac arrhythmia, according to a 19-page coroner’s report obtained by ABCNews.com. And while Harris, a mother of eight from Invercargill, New Zealand, was known to smoke heavily and skip multiple meals, coroner David Crerar concluded that the sugar and caffeine she got by drinking more than 2.6 gallons of Coca-Cola Classic per day was “a substantial factor” in her death. When all of the available evidence is considered, were it not for the consumption of very large quantities of Coke by Natasha Harris, it is unlikely that she would have died when she died and how she died,” Crerar wrote in his report.” This statement is not false just misleading.
The initial report by the coroner was less interesting, lacked his narrative, but was more accurate. “Natasha Harris went into cardiac arrest in February 2010 and died at the age of 30. At the time of her death, a pathologist found Harris had hypokalemia, or a lack of potassium in the blood.” This is a factual description of her death. After the full evaluation by the coroner he has come to some conclusions. The conclusions are more of a opinion than a fact. “Natasha Harris knew, or ought to have known and recognized, the health hazard of her chosen diet and lifestyle,” Crerar wrote in his report, adding that fact that Harris had her teeth extracted several years before her death “should have been treated by her, and by her family, as a warning.” I am going to give the Coroner a pass and point out that the next quotes were cherry picked out of a 19 page report. “While Crerar noted that the ingredients of Coke are “entirely legal” and “enjoyed by millions,” he said the risks of high doses were not adequately communicated to consumers. The hazards to the health of the consumers of excessive quantities of sugar and caffeine contained in carbonated beverages could be more clearly emphasized,” he wrote.” The coroner has recommended “warning labels on soft drinks”.
Some articles noted the following; her child was born without dental enamel, and she smoked 30 cigarettes a day. She was not obese, and consumed little or no food.
I will try to break down the medical facts of this story and what is probably the medical truth. She drank exclusively Coca Cola 10 liters a day for years. That is equivalent to 2.2 pounds of raw sugar and 10 liters of water a day. For a cause of death the other ingredients are irrelevant. She ate little food. On a basic nutritional level she was malnourished. More importantly she showed clinical symptoms of psychogenic polydipsia. A psychiatric condition where patients habitually drink to relieve stress. While many adult cases in the medical literature are associated with mental disorders, most patients with habit polydipsia have no other detectable disease. Without a physical exam and thorough history it is difficult to diagnose. Psychogenic polydipsia is consistent with the evidence as presented. Drinking 2.6 gallons daily of any liquid is by definition polydipsia. The ironic upside is that the sodium and the sugar in the coke was probably keeping her alive. If she drank that much straight water daily she would have developed diabetes insipidus rapidly and died from seizures related to hyponatremia years ago. The concentrated sodium and sugar probably balanced her serum osmolality.
The Coroner maintains that the caffeine in the soda was the primary factor in the cardiac arrhythmia and subsequent arrest. I cannot say for certain but I find it unlikely that it was a primary cause for two reasons. She was no where near the LD50 for an adult greater than 100 pounds. She would need 9000mg for a 60Kg female to be at LD50. That is not a recommended upper limit for caffeine just an animal model guideline Caffeine naive people have died at 2 gram doses when taking caffeine pills. Pills are a large dose in a short time. In toxicity studies with coffee the caffeine washed out quickly and it was difficult to produce toxic effects in animal models. 10 liters of Coke is 2000 mg approx. She wouldn’t drink them at one sitting so it was unlikely to be close to a toxic dose. Secondly she had drank that amount of caffeine for years. She was probably hugely tolerant. I would be like trying to OD a alcoholic with one bottle of wine. She would just look for more. The family stated that she was dependent upon the caffeine and had symptoms of withdrawal when she didn’t drink that much. Caffeine can be a trigger for arrhythmia, in this case, far less of risk than the other risks she was assuming.
Here is a list of several good reasons for her cardiac arrest. She smoked 30 cigarettes a day. She was chronically malnourished. Her primary calories came from sugar. She was protein deficient and most likely calcium and potassium depleted. She had liver disease according to her family. This makes her other method of osmolality control, plasma proteins, out of wack. This is supported by the lab work. Add these factors to 10 liters of water daily and you have rapid diabetes insipidus. She was a ticking time bomb for a seizure or fatal cardiac arrhythmia. Caffeine is not at the top of my list for problems.
You have an undernourished thin, vitamin and protein deficient female. Smoking 30 cigarettes a day with diabetes insipidus due to polydipsia. Why is caffeine a major factor? That is like saying that the world trade center buildings fell because of the weight of 3000 people in the buildings.
As for the coroner recommending warning labels on sugar soda, not really needed in this case. If you are drinking that much of anything daily you are going to have problems. What will it read? “Warning drinking 2-3 gallons of this fluid a day for for years without food may lead to health problems or death!”. No Kidding.
It was reported that her children were born without dental enamel. No cola does not have the ability to rot your teeth before they emerge. In fact it is a sign of malnourishment and vitamin A,C, or D deficiency intrapartum.
I think that the evidence boils down to a psychiatric condition, chronic polydipsia, malnutrition, and resulting electrolyte imbalance with complications secondary to that condition. The arrhythmia may have been triggered by daily exposure to high caffeine levels. More likely that she had run out her body’s ability to deal with the crushing problems of poor nutrition and polydipsia. The label on the bottle was irrelevant. You could make an argument that Gatorade would have been better and straight water worse.
Given this quote from the family I find little evidence that a warning label would have helped. “Her heart would race, her liver was swollen, and her rotting teeth had to be removed. But, said the report, “the family did not consider that Coke was harmful due to the fact of it having no warning signs.”
I think that says it all in this case.
1: Equine poisoning by coffee husk (Coffea arabica L.)
Diego Jose Z Delfiol, Jose P Oliveira-Filho, Fernanda L Casalecchi, Thatiane Kievitsbosch, Carlos A Hussni, Franklin Riet-Correa, João P Araujo-Jr , Alexandre S Borges
BMC Vet Res. 2012; 8: 4. Published online 2012 January 12. doi: 10.1186/1746-6148-8-4
2: Caffeine, cognitive functioning, and white matter lesions in the elderly: establishing causality from epidemiological evidence
Karen Ritchie, Sylvaine Artero, Florence Portet, Adam Brickman, Jordan Muraskin, Ephrem Beaino, Marie-Laure Ancelin, Isabelle Carrière
J Alzheimers Dis. Author manuscript; available in PMC 2010 August 30.Published in final edited form as: J Alzheimers Dis. 2010; 20 Suppl 1: S161–S166. doi: 10.3233/JAD-2010-1387
3: Caffeine protects against disruptions of the blood-brain barrier in animal models of Alzheimer’s and Parkinson’s disease
Xuesong Chen, Othman Ghribi, Jonathan D. Geiger
J Alzheimers Dis. Author manuscript; available in PMC 2011 May 3.Published in final edited form as: J Alzheimers Dis. 2010; 20(Suppl 1): S127–S141. doi: 10.3233/JAD-2010-1376
4: Sex Differences in Caffeine Neurotoxicity Following Chronic Ethanol Exposure and Withdrawal
Tracy R. Butler, Katherine J. Smith, Jennifer N. Berry, Lynda J. Sharrett-Field, Mark A. Prendergast
Alcohol Alcohol. 2009 Nov-Dec; 44(6): 567–574. Published online 2009 September 16. doi: 10.1093/alcalc/agp050