Transcript Infant feeding practices: Getting to the details La Leche

Reduction of SugarSweetened Beverage
Consumption
Jean A. Welsh, MPH, RN
Susan Anderson, MS, RD
Winifred King, PhD
Bettylou Sherry, PhD
CDC State Partners Meeting
November 13, 2008
Session Objectives
Presentation
 Describe why reduction of SSBs is a CDC priority
 Highlight federal, state, and local initiatives to reduce
SSB consumption
 Summarize evidence of effectiveness of interventions
to reduce SSB consumption
 Present proposed key Strategies & Action Steps
 Introduce plans for the CDC Guide to Reducing Sugar-
Sweetened Beverage Consumption
Follow-up Discussion
 Elicit input from state partners & colleagues
regarding:
– Plans for the CDC Guide
– Future collaboration
SSB Definition and
Consumption Trends
What are Sugar-Sweetened
Beverages (SSBs)?

Beverages with sugar added:
– during industry processing
– during preparation by consumer


Includes: Non-diet carbonated soft drinks
(soda or pop), fruit drinks/ades, teas and
coffees, sports drinks and flavored milks
Does not include 100% juice
Added Sugars
Source: USDA Dietary Guidelines for Americans, 2005
Common Beverage Sweeteners
Sucrose


naturally occurring
50% fructose, 50% glucose
HFCS: A Sugar By Any
Other Name…
HFCS


Conversion of glucose from corn
to fructose
Product combined with glucose
in varying proportions
– 42% fructose

Processed foods
– 55% fructose


Beverages
Less expensive than sucrose
Source: HFCSfacts.com
SSB Consumption Trends

SSBs largest single source of calories
in the US diet
– 1965: 50 kcal/day
– Today: children/youth 224 kcal/day

Increases:
prevalence
 frequency
 amount

Change in Caloric Intake
from SSB by Age
Percent daily calorie intake
14
12
2-18 y
10
19-39 y
8
40-59 y
6
>=60 y
4
2
0
77-78
89-91
Source: Nielsen and Popkin AJPM, 2004
94-96
99-01
Contextual Factors
JIU#4648623
Factors Associated with SSB
Consumption

Knowledge

Increased advertising and marketing

Increased portion sizes

Increased fast foods

Increased TV watching

Parenting practices and home environment

School environment

Preference for sweet taste
Knowledge

School-based nutrition
education programs
reduced SSB intake
(James, 2006; Contento, 2007,
Sichieri, 2007)
Increased advertising and
marketing



Hundreds of new
beverages introduced
each year (ERS/USDA, 2005)
$100’s millions for
advertising & promotion of SSBs
Advertising to children/youth influences
their preferences & requests for high
calorie, low-nutrient-dense food and
beverages (IOM, 2005)
Increased portion sizes



Since the 1960s the industry has increased
the single-serving size from a standard 6½-ounce bottle to a 20- ounce bottle.
Serving a larger portion of a beverage
increases beverage consumption
With increased calorie-containing
beverages, energy intake increases
(Flood, 2006)
Increased Fast Foods

SSB consumption increases for both
boys and girls as weekly fast
food consumption
increases (French, 2001)
Increased TV Watching


Depending on their age, youth view between 12
and 21 commercials for food or beverages every
day (RWJF, 2008)
For each 1-hour increment of TV viewing per day,
SSB intakes were shown to increase 0.06 servings
(Miller, 2008).
Parenting practices & home
environment

Permissive parenting
– Permissiveness to requests for SSBs
and catering to demand of children
correlated with children’s SSB consumption (Haerens, 2008)

Modeling of dietary behavior
– Children’s consumption strongly correlated with their
parents, particularly their mother’s (Vereecken, 2004)
– Youth whose parents drink SSBs are nearly 3 x more likely
to drink SSBs > 5x/week (Grimm, 2004)

Access to SSBs
– Home source of majority of SSBs consumed (Wang, 2008)
School environment

Access
– 33% elementary, 71% middle and 89% HS have a vending
machine, school canteen, etc. where SSBs can be purchased
(SHPPS, 2006)
– 90% schools offer a la carte lunch (School Nutrition Dietary
Assessment Study, 2001).
– School lunch consumers- 1/3 < sugar (Cullen, 2004)

Pouring contracts
– Long-term agreement between supplier and schools whereby
schools earn income in proportion to school beverage sales
– Most students (67% in middle and 83% in high school) are in
schools that have a contract with a bottler (Johnston, 2007)

Advertising & promotion
– Advertising  with pouring contracts (Probart, 2006)
Sweet Taste Preference



Begins en utero
Taste preference important
in decision to consume SSBs
(Grimm, 2004)
Sugar sweetness, when accompanied by
calories, may overwhelm the body’s
physiological satiety mechanisms, leading
to overeating (Rodin, 1975; Blundell et al.,
1994; Blundell and Green, 1996).
SSBs and Health Outcomes
SSB Consumption and Obesity
Source: Johnson, R. J et al. A m J Clin Nutr 2007;86:899-906
Studies: SSBs and Energy Intake
and Weight
SSBs & Energy Intake
Positive
Null
Inconsistent
10
1
1
Longitudinal
5
-
-
Short-term experimental
5
5
2
Long-term experimental
4
-
-
Positive
Null
Inconsistent
11
11
-
Longitudinal
5
5
1
Long-term experimental
4
2
-
Cross-Sectional
SSBs & Weight
Cross-Sectional
Source: Vartanian et al, AJPH, 2007
SSBs and Energy Intake/Weight
Summary of findings


Effect size small, highly variable by outcome
measure
Effect sizes largest in experimental vs crosssectional studies
–
–
–
–
Women
Adults
Studies of carbonated soda
Studies not funded by food industry
Source: Vartanian LR, et al. AJPH 2007
Biological Mechanisms:
SSBs and Weight
SSB
+
energy intake
+

Preference for sweet taste

Glycemic response


weight
Liquid calories, failure to compensate
for excess energy intake
Effect of fructose metabolism on
satiety hormones
Other Health Outcomes






Dental caries
Type 2 diabetes
Liver disease- NAFLD
Dyslipidemia
Decreased bone density
Nutrient displacement
Public Health
Interventions
Social Ecological Model
Multi-level intervention: Society, Community, Organizational,
Interpersonal and Individual
 Multiple strategies: Policy, environment, information-based

Federal Legislation
School Access

USDA National School Food Programs
National Wellness Committees & Policies

WIC Reauthorization Act
Labeling

FDA
Advertising

FTC
State Legislation: Schools





Elimination of all beverages that contain caloric
sweeteners except milk - Kentucky, Tennessee,
Louisiana
Limiting marketing to only healthy beverages Alabama.
Adjusting the container size for the beverage type and
the age of the targeted consumers - Alabama and
Kentucky
Prohibits use of beverages as reward or punishment Arkansas
Ensuring availability of healthful beverages (i.e. bottled
water or low-fat milk) whenever beverages are offered
or sold - 17 % of state
Sources: Mello, Am J Public Health. 2008 Apr;98(4):595-604
http://www.schoolbeverages.com/research--faqs/school-wellness-policies/
download.aspx?id=59;
State Legislation: Childcare

Limit SSBs for all
– NM

Limiting SSBs for infants < 12 months
– OR

Prohibits giving foods with corn syrup to infants
– CA

SSBs served on limited occasions
– GA, NC, NV

No fruit ades, drinks, soft drinks, or powders
served or accessible to children
– IN
Source: Benjamin et al., BMC Public Health, 2008
Local Policies and
Guidelines

School Beverage Guidelines, Alliance for Healthier
Generations
– Voluntary guidelines between schools and their suppliers
– Restrict beverage sales to water, low-fat milk, 100%
juice; plus sports drinks and diet sodas in high school

Los Angeles Unified School District
– prohibits the sale of drinking water with additives other
than those normally added to tap water;
– also prohibits milk products with > 8 grams (32 calories)
of added sweetener per 8 oz or are sweetened with
artificial sweetener.

Mississippi middle school
– students are allowed to bring water into the classroom.
Effectiveness of Interventions
Literature review


No reviews or meta-analyses
13 studies with SSB as an outcome, 12 reduced SSBs
Targets

Children, ages 1 to 18 y
Settings



Schools: middle & high school (5);
Community-based: homes (2); community (5)
Health care setting (1)
Intervention strategies




Policy component (0)
Education only (6)
Environmental change only (0)
Parental involvement (5)
Evidence Gaps

Limited studies, issues of:
–
–
–
–



Generalizability
Reliability
Feasibility
Long-term impact
Lack of program impact evaluations
Importance of contextual factors
Effect of replacement with “healthy”
alternative
Expanding the Evidence Base


Need systematic way to evaluate
health behavior interventions
RE-AIM
–
–
–
–
Reach into the target population
Efficacy or effectiveness
Adoption by target settings or institutions
Implementation—consistency of delivery of
intervention
– Maintenance of intervention effects in
individuals and populations over time.
Source: re-aim.org
Strategies & Action Steps
“Healthy” Alternative?





*Water
*1% or skim milk
*100% fruit juice
Sports drinks?
Diet drinks?
Community-based:
1. Promote access to and consumption of
quality drinking water
Rationale



Refreshing calorie-free alternative
Substituting SSBs with water associated with
↓ total energy intake (Wang, 2008)
Quality drinking water not always readily accessible
Effectiveness
?
Potential Action Steps


Ensure free access to quality drinking water in all public facilities,
including schools, parks, playgrounds, worksites, etc.
Ensure quality, potable drinking water in all households served by
community water systems
Community-based:
2. Support the establishment and maintenance of a
nutritionally healthy home environment
Rationale




Homes where eating behaviors adopted by children are modeled
Parenting behaviors & SSB consumption
associated with children’s consumption
Home is the source of most SSBs consumed
Fast food & TV associated with SSBs
Effectiveness

HIKCUPS study showed that dietary changes aimed at parents can
improve diets of young children (Burrow, 2008)
Potential Action Steps


Offer training to build parenting skills related to child feeding
practices in locations easily accessed by adults, i.e worksites,
places of worship
Support initiatives that encourage families to prepare and eat more
meals at home and to limit time spent watching TV.
Community-based:
3. Early intervention to establish healthy beverage
consumption patterns
Rationale



Eating behaviors established early in childhood,
track into adulthood
~74% of kids 3 to 6 y attend non-parental care
7 states have policies that restrict SSBs in child cares
Effectiveness`

? Effectiveness of child care-based interventions
Potential Action Steps



Provide assistance & support to guide the development and
maintenance of healthy nutrition environment in child cares
Utilize state/local licensing requirements to ensure that child
care staff are provided with essential nutrition education
Provide nutrition education for parents through day cares
Community-based:
4. Minimize the impact of advertising and promotion
of SSBs
Rationale


Beverage industry $$ advertising and promoting SSBs. Among
ads viewed by children, 99% beverages high in added sugar
Intensive advertising influences child & youth preferences & 
requests for high calorie and low-nutrient-dense food/beverages
Effectiveness

?
Potential Action Steps



Advocate with state and local policy makers to restrict advertising
of SSBs aimed at children
Advocate with the beverage industry to promote beverage
alternatives that help meet nutrient needs, such as low-fat milk,
100% juice, and water in place of SSBs
Provide media literacy training, particularly for children.
School-based:
1. Minimize access to SSBs; promote healthy
options
Rationale

Many have access to SSBs in school, even during lunch
Effectiveness



Alliance for Healthier Generation: 58% fewer
calories shipped 2004 & 2007-08
(www.healthiergeneration.org)
Zuni Diabetes Prevention Project: replacing SSBs
with water/diet drinks stopped SSB consumption in school
(Ritenbaugh, 2003)
Energy content labels, promotion of diet drinks on vending
machines  sales, primarily diet (Bergen, 2006)
Potential Action Steps



Develop policies that eliminate sale of SSBs at school
Redefine or eliminate beverage “Pouring Contracts”.
Ensure that quality drinking water is readily accessible
Photo: www.healthier generation.org
School-based:
2. Eliminate advertising of SSBs and its effect on
children
Rationale


Most students are in schools that have a contract with a bottler
Promotion of SSBs is greater in schools that have beverage
pouring contracts with suppliers
Effectiveness
?
Potential Action Steps


Eliminate promotion and advertisements of SSBs in schools.
Explore options for replacing them with ads for beverages that
provide nutrients that tend to be deficient in the diets of children
and adolescents.
Provide media literacy training for students
School-based:
3. Provide nutrition education for students and
teachers
Rationale


Education is important tool for behavior change
Important to have supportive environment
Effectiveness

Studies among students in Brazil, England and U.S.
have shown the a nutrition education focused
intervention could reduce SSBs
Potential Action Steps

Incorporate nutrition education into core curriculum as
a component of a comprehensive SSB reduction
program.
Worksite:
1. Encourage efforts to establish a work
environment that supports good nutrition
Rationale


The environment plays an
important role in health behaviors
Employees in worksite nutrition
education programs potentially
become role models for their own family members &
other employees
Effectiveness

?
Potential Action Steps


Support efforts to provide nutrition education at work
Encourage reduction of vending machines selling SSBs,
place them on first floor only
Primary Health Care:
1. Dietary Screening and Nutrition Advice
Rationale

Health care providers have contact with nearly all children and
youth in the United States; visits provide opportunities for
educating & motivating regarding behavior change.
Effectiveness

Providers use of AAP’s 5-2-1-0 program
increases nutrition counseling
regarding SSB consumption (Maine Youth
Overweight Collaborative, 2006)
Potential Action Steps


Expand use of screening guides such as 5-2-1-0 to facilitate
physician screening and counseling
Advocate with insurance providers to support reimbursement for
nutrition screening & counseling
“To obtain more evidence-based
practice we need more practicebased evidence”
Green L, Ottoson JM. In Hiss et al, From Clinical
Trials to Community: the Science of Translating
Diabetes and Obesity Research, NIH, 2004.
Monitoring & Evaluation of
SSB Reduction Activities
Monitoring & Evaluation
CDC – SSB Consumption Measures

CSFII/NHANES
– 24 hour dietary recall
– FFQ, “How often do you drink other fruit drinks (such as
cranberry cocktail, Hi-C, lemonade, or Kool-Aid, diet or
regular)? and “How often were your fruit drinks diet or
sugar-free drinks? “

Youth Risk Behavior Survey (YRBS)
– Biennially, question added 2001
– During the past 7 days, how many times per day did you
usually drink a can, bottle, or glass of soda or pop, such
as Coke, Pepsi, or Sprite? (Do not include diet soda or
diet pop.)
Monitoring & Evaluation (2)

YRBS (Special Survey 2010)
…sugar sweetened beverages such as lemonade, sweet tea, punch,
Kool-Aid or fruit juices that are not 100% fruit juice (do not count
100% fruit juice or diet drinks)?
… diet drinks, such as diet soda, diet pop, diet tea, or Crystal
Light?
… sports or energy drinks, such as Gatorade or Powerade? (Do not
count energy drinks such as Red Bull.)
… water (include tap water, bottled water, and unflavored seltzer water)?
… caffeinated beverages, such as coffee, tea, soda or pop, Red
Bull, or Jolt?
… vitamin water?
Monitoring & Evaluation (3)
State - SSB Consumption Measures

Massachusettes- Healthy Choices Survey, 2005
–
Think about the past 7 days and tell us how often you drink the
following items
i.
Soda (NOT DIET) (1 can or glass; count a 20 oz bottle as
two glasses):
ii. Diet Soda
iii. Flavored drinks including punch, sports drinks like
Gatorade®, sweetened ice tea or other fruit-flavored drinks
like Kool-Aid® and Hawaiian Punch®. Do NOT count 100%
fruit juice.
iv. Water (tap, spring, or sparkling)
v. Milk including white milk, Lactaid®, chocolate milk or other
flavored milk like strawberry, vanilla or coffee. (carton,
glass or with cereal)
Monitoring and Evaluation (4)
CDC - Process measures

Common Community Measures for Obesity
Prevention (COCOMO)
– Community-based indicators to be determined

School Health Policies and Programs Study
(SHPPS)
– Availability of soft drinks in schools
– Every 6 years, began 1994, SSB 2000

School Health Profiles
– Conducted biennially to assess characteristics of
school health programs
Monitoring and Evaluation
(5)

DNPAO Legislative database
– Fate of bills with “beverage”, 2001-08
Enacted
37
Pending
Changed
Dead
25
4
139
Monitoring and Evaluation
Gaps




Lack of standardized definition of SSBs
Lack of standardized indicators for
assessing individual SSB intake
Lack of standardized methods for
monitoring policy and environmental
change
Need to report results
CDC Activities & Resources
CDC Resources & Activities

Surveillance Systems
– NHANES, SHPPS, YRBS, Profiles, DNPAO Legislative Database

Does Drinking Beverages with Added Sugars Increase
the Risk of Overweight? Research to Practice Series No.
3 (practitioners)

Rethink Your Drink (consumers)

DNPAO Technical Assistance Manual

Special Interest Project (SIP) – UCLA, qualitative study
factors in the home that influence beverage consumption
CDC Guide to Reducing SSB
Consumption





Consumption trends
Associated health outcomes
Factors associated with consumption
Pros and cons of beverage alternatives
Key strategies (by setting)
–
–
–
–
–
–

Rationale
Evidence of effectiveness
Program examples
Barriers identified/Lessons learned
Potential action steps
Resources
Monitoring & evaluation resources
THANKS !
Discussion: CDC Guide




Is content appropriate?
Will it meet your program planning
needs?
If not, what’s missing?
Are there components missing that
might be important to your key
partners?
Discussion: Future
Collaboration


What do you need most to ensure the
effectiveness of your efforts to reduce SSB
consumption?
How can CDC and State Partners best work
together to advance work in this area?
– Information on latest research
– Facilitate information sharing on interventions
– How is information best shared


State focal points?
Listserv?