RECOMMENDATION 2

Food and beverage environments are one of the five critical areas for accelerating progress in obesity prevention identified by the committee (Figure 6-2).12 Increasing access to healthy food and beverage options and decreasing consumption of solid fats and added sugars are important steps toward achieving energy balance when implemented together with adequate levels of physical activity ( Chapter 5). The eating patterns of Americans cannot be changed in isolation. Major changes in the nation’s food system and food and eating environments have occurred in recent decades, driven by technological advances; U.S. food and agriculture policies; population growth; and economic, social, and lifestyle changes (Story et al., 2008). Food now is readily available and accessible in many settings throughout the day. The current U.S. food supply contains a large amount of energy-dense foods, many of which consist of refined grains and foods high in fats and/or sugars and low in nutrients. Many of these foods are often available in increasingly large portion sizes at relatively low prices (Story et al., 2008). Americans also are eating out more often and consuming more calories away from home than ever before (Keystone Forum, 2006), and families are eating fewer meals together (Neumark-Sztainer et al., 2003). In addition, the school food environment is radically different than it was a few decades ago, with many schools now offering and promoting high-calorie, low-nutrition foods throughout the school day (Fox et al., 2009). Food marketing aimed at children using multiple channels, such as digital media, has increased dramatically as well (RWJF, 2011). Finally, an exodus of grocery stores and an influx of fast-food restaurants in lower-income urban areas have contributed to income and racial/ethnic disparities in access to healthier foods (IOM, 2005). Together, these environmental changes have influenced what, where, and how much Americans eat and have played a large role in the current obesity epidemic (IOM, 2009).

FIGURE 6-2

Five areas of focus of the Committee on Accelerating Progress in Obesity Prevention. NOTE: The area addressed in this chapter is highlighted.

To change American’s eating patterns, a sustained, systematic and comprehensive approach is required that empowers consumers to make healthy choices; that gives them a variety of affordable, healthy options from which to choose; that promotes consistent messages about the importance of healthy eating in concert with daily physical activity; that makes healthy food options readily available and accessible; and that cuts across all sectors of society—from government, to schools, to restaurants and privately run places of public access, to health care settings, to farming. Absent a multifaceted approach, the nation will be no better off in 2022 than it is in 2012. The time for change is now. The committee recommends making the healthy option the routine, readily available, and affordable option and provides five strategies and potential actions for implementing this recommendation. These strategies and actions are detailed in the remainder of this chapter. Indicators for measuring progress toward the implementation of each strategy, organized according to the scheme presented in Chapter 4 (primary, process, foundational) are presented in a box following the discussion of each strategy.

STRATEGIES AND ACTIONS FOR IMPLEMENTATION

Strategy 2-1. Adopt Policies and Implement Practices to Reduce Overconsumption of Sugar-Sweetened Beverages

Decision makers in the business community/private sector, in nongovernmental organizations, and at all levels of government should adopt comprehensive strategies to reduce overconsumption of sugar-sweetened beverages.⁸

For schools and other locations where children and adolescents are cared for, potential actions include

• prohibiting access to sugar-sweetened beverages;
• providing a variety of beverage options that are competitively priced and are recommended by and included in the Dietary Guidelines for Americans; and
• making clean, potable water available.

For the business community/private sector, nongovernmental organizations, and governments, potential actions include

• making clean, potable water readily available in public places, worksites, and recreation areas;
• making a variety of beverage options that are competitively priced readily available in public places, worksites, and recreation areas;
• implementing fiscal policies aimed at reducing overconsumption of sugar-sweetened beverages through (1) pricing and other incentives to make healthier beverage options recommended by the Dietary Guidelines for Americans more affordable and, for governments, (2) substantial and specific excise taxes on sugar-sweetened beverages (e.g., cents per ounce of liquid, cents per teaspoon of added sugar), with the revenues being dedicated to obesity prevention programs;
• supporting the work of community groups and coalitions to educate the public about the risks associated with overconsumption of sugar-sweetened beverages; and
• developing social marketing campaigns aimed at reducing overconsumption of sugar-sweetened beverages.

For the food and beverage industry, potential actions include

• developing and promoting a variety of beverage options for consumers, including a range of healthy beverage options, beverages with reduced sugar content, and smaller portion sizes (e.g., 8-ounce containers).

For health care providers such as physicians, dentists, registered dietitians, and nurses, potential actions include

• performing routine screening regarding overconsumption of sugar-sweetened beverages and counseling on the health risks associated with consumption of these beverages.

Context

Consumption of sugar-sweetened beverages is the single largest contributor of calories and added sugars to the American diet (HHS/USDA, 2010; NCI, 2010b; Welsh et al., 2011). Such beverages also displace healthier, more nutrient-dense beverages such as milk, 100 percent fruit juice, and water (Woodward-Lopez et al., 2010).

According to National Health and Nutrition Examination Survey (NHANES) 2005-2006 dietary intake data, sugar-sweetened beverages represent the largest share of calories in the diets of all individuals aged 2 and above⁹—more calories than are contributed by any other food category, including grain-based desserts, yeast breads, and chicken and chicken mixed dishes. Using the same NHANES data, Reedy and Krebs-Smith (2010) show that for children and adolescents aged 2-18, sugar-sweetened beverages were the largest contributor—22 percent—to empty calorie intake (that is, calories from solid fat and added sugars).

On a given day, one-half of the U.S. population aged 2 and older consumes sugared drinks (excluding ready-to-drink sugar-sweetened teas and coffees) (Ogden et al., 2011). According to NHANES data for 2005-2008, 25 percent of Americans drink more than one sugared drink daily (200 kcal/day), 20 percent consume one to four such drinks a day (200-566 kcal/day), and 5 percent drink more than four such drinks daily (567 kcal/day) (Ogden et al., 2011).

Consumption of sugar-sweetened beverages is not limited to particular segments of the U.S. population, although certain groups are more likely to consume them than others. According to Ogden and colleagues (2011), males are more likely than females to consume sugared drinks, with males aged 2-19 most likely to do so (70 percent) on a given day and females aged 20 and older least likely to do so (40 percent). At the same time, sugared drinks represent a greater percentage of daily caloric intake for certain racial/ethnic groups (Ogden et al., 2011). Sugared drink consumption represents 8.5 percent of total daily kilocalories for non-Hispanic black children and adolescents aged 2-19 as compared with 7.7 percent and 7.4 percent of total daily kilocalories for non-Hispanic whites and Mexican American children and adolescents, respectively (Ogden et al., 2011). For Americans aged 20 and over, the racial/ethnic disparity in sugared drink consumption is even greater—8.6 percent of total daily kilocalories consumed by non-Hispanic blacks were from sugared drinks as compared with 5.3 and 8.2 percent for non-Hispanic whites and Mexican Americans aged 20 and over, respectively (Ogden et al., 2011). Consumption of sugared drinks also is lower among higher-income than lower-income persons, with such differences being particularly noticeable among adults aged 20 and over (Ogden et al., 2011).

Of particular concern are the added sugars attributable to excess consumption of sugar-sweetened beverages overall. According to NHANES 2005-2006 dietary intake data, sugar-sweetened beverages are the largest contributor to added sugars in the diets of all individuals aged 2 and above.¹⁰ While added sugar intake has declined for Americans aged 2 and older, largely because of reduced consumption of regular sodas, added sugar intakes continue to exceed dietary recommendations, and rates of consumption of energy drinks as a source of added sugars have increased significantly over the past decade (Welsh et al., 2011). If people are to meet the Dietary Guidelines for Americans’ recommended food pattern/caloric intake for their age, sex, and activity level, they must minimize their intakes of all solid fats and added sugars. While the maximum recommended limits for solid fats and added sugars vary by age, sex, and level of physical activity, these limits are intended to reflect intakes of both solid fats and added sugars. Yet in most cases, more than half of the recommended calories from solid fats and added sugars being consumed are from sugared drinks; in many cases, more than two-thirds of the recommended calories from solid fats and added sugars are attributable to sugared drink consumption (Figure 6-3). In other words, Americans’ current rates of sugared drink consumption leave very little room in their diet for any additional solid fats and added sugars, and in some cases (e.g., males aged 6-8 and 12-13), they exceed the daily recommendations for solid fats and added sugars with their sugared drink consumption alone. As the Keystone Forum¹¹ (2006) notes in its recommendations for preventing weight gain and obesity, several dietary factors contribute to the development of obesity (a detail that the Forum participants recognized), “and one of those factors is excess caloric intake. A decrease in caloric beverage consumption is just one of many necessary strategies in the effort to reduce obesity.”

FIGURE 6-3

Percentage of daily caloric limit of solid fats and added sugars from sugared drink consumption for given ages, assuming moderate activity level. NOTES: Moderate physical activity is defined as a lifestyle that includes physical activity equivalent to walking (more...)

Evidence

Despite the complexity of the etiology of obesity and the difficulty of quantifying relative contributions to the obesity epidemic, researchers have found strong associations between intake of sugar-sweetened beverages and weight gain. Although the exact mechanisms of how sugar-sweetened beverages contribute to obesity are not fully known, their link to obesity is stronger than that observed for any other food or beverage, as described in the 2010 Dietary Guidelines for Americans advisory report (DGAC, 2010). Woodward-Lopez and colleagues (2010) found that sugar-sweetened beverages account for at least 20 percent of the increases in weight in the United States from 1977 to 2007. Others have concluded that liquid calories supplied approximately half of the 150- to 300-calorie increase in daily energy intake observed over the past 30 years (Johnson et al., 2009), concomitant with no apparent change in physical activity (Briefel and Johnson, 2004; Nielsen et al., 2002). Additional evidence supporting the reduction of sugar-sweetened beverages in order to promote energy balance is predicated on evidence suggesting that liquid calories from sweet, energy-dense beverages are poorly compensated for by reduced dietary intake from other sources (Bellisle and Rolland-Cachera, 2001; DiMeglio and Mattes, 2000; Mattes, 1996; Popkin and Duffey, 2010).

The 2010 Dietary Guidelines Advisory Committee (DGAC) concluded that for adults, “limited evidence shows that intake of SSBs [sugar-sweetened beverages] is linked to higher energy intake… a moderate body of epidemiologic evidence suggests that greater consumption of SSBs is associated with increased body weight in adults, and a moderate body of evidence suggests that under isocaloric controlled conditions, added sugars, including sugar-sweetened beverages, are no more likely to cause weight gain than any other source of energy” (DGAC, 2010, p. 301). The 2010 DGAC found a more robust link between sugar-sweetened beverages and childhood adiposity, concluding that “strong evidence supports the conclusion that greater intake of SSBs is associated with increased adiposity in children.” The DGAC recommended a “greatly reduced” intake of sugar-sweetened beverages to prevent excess weight among children, noting that consumption should also be discouraged because of the need to replace empty calories with nutrient-rich energy for optimal growth and development (DGAC, 2010, p. 12).

The contributions of the consumption of sugar-sweetened beverages to childhood obesity also will likely lead to greater future prevalence of adult obesity. The established habitual nature of consumption of these beverages suggests that their consumption is likely to persist into adulthood, further increasing the risk for obesity (Popkin and Duffey, 2010).

Because 100 percent fruit juice is suggested as an alternative to sugar-sweetened beverages and there may be concern that its calorie content will promote obesity, the committee cites the DGAC report, which states: “limited and inconsistent evidence suggests that for most children, intake of 100 percent fruit juice is not associated with increased adiposity when consumed in amounts that are appropriate for age and energy needs of the child.” The report also notes, however, that intake of 100 percent fruit juice has been prospectively associated with increased adiposity in children who are overweight or obese (DGAC, 2010). Furthermore, the report explains that although 100 percent fruit juice provides nutrients and can be part of a healthy diet when consumed in moderation,¹² it lacks dietary fiber and can contribute extra calories when consumed in excess; thus, the majority of fruit servings should come from whole fruits.

Implementation

Recognizing the trends described above, a number of prior Institute of Medicine (IOM) committees have recommended strategies aimed at reducing consumption of and exposure to sugar-sweetened beverages, as well as encouraging consumption of healthier beverages. Nutrition Standards for Foods in Schools: Leading the Way Toward Healthier Youth (IOM, 2007a) recommends that beverages provide no more than 35 percent of calories from total sugars per packaged portion, with the exception of 100 percent fruit juices and 100 percent vegetable juices without added sugars and unflavored nonfat and lowfat milk. The same report also recommends that sports drinks be available in schools only for student-athletes participating in vigorous-intensity sports for at least 1 hour. Likewise, the IOM (2009) has recommended that local governments ensure that publicly run entities promote healthy beverages. It has also recommended that restaurants promote healthier options, such as by serving nonfat milk instead of soda in children’s meals (IOM, 2006b, 2009); that food, beverage, restaurant, retail, and marketing industry trade associations improve the availability and selection of healthful beverages accessible at eye level and reach in grocery stores and retail environments (IOM, 2006b); that the media promote healthful beverages (IOM, 2006b); that industry shift product portfolios and advertising and marketing emphasis toward beverages substantially lower in total calories and added sugars and higher in nutrient content (IOM, 2006b); and that caregivers of young children (birth to 4 years) build skills to foster the selection of healthful beverages (IOM, 2006b).

Likewise, a number of medical, public health, scientific, policy-making, nonprofit, and consensus-building bodies have specifically identified reduced consumption of sugar-sweetened beverages and/or excess caloric intake associated with such consumption as key issues requiring a societal response that involves not only governments but also, just as important, schools, industry, food service providers, and medical care providers. The Dietary Guidelines for Americans (HHS/USDA, 2010), the American Academy of Pediatrics in association with the American Heart Association (Gidding et al., 2006), and the American Medical Association (AMA, 2007) all recommend reducing intake of sugar-sweetened beverages because they are the leading contributor to excess sugar consumption in the American diet. And the Centers for Disease Control and Prevention (CDC) (2010) has identified seven recommended strategies for reducing consumption of sugar-sweetened beverages that are aligned with actions outlined above by the committee. The following discussion briefly summarizes the evidence, positions, and, where available, implementation experiences related to the overall strategy of reducing consumption of sugar-sweetened beverages.

Access to sugar-sweetened beverages in public places and schools

The U.S. Surgeon General (2010), the Department of Health and Human Services (National Prevention Council, 2011), the National Governors Association (Mulheron and Vonasek, 2009), the National Association of Local Boards of Health (2010), CDC (Khan et al., 2009), the Alliance for a Healthier Generation (2006), the American Dental Association (2005), and the American Academy of Pediatric Dentistry (AAPD, 2010) all recommend a range of strategies for reducing consumption of sugar-sweetened beverages. These strategies include eliminating or restricting access to sugar-sweetened beverages, including those sold through vending machines and in schools, child care/early learning centers, and other government facilities and public places and increasing access to healthier options, such as bottled water and non- or low-fat milk. Likewise, given the wide availability of sugar-sweetened beverages in workplaces, schools, recreation facilities, entertainment venues, and other places frequented by the public, a number of organizations have recognized the need to ensure that Americans have sufficient alternatives to such beverages available, and have identified specific strategies to that end. The Keystone Forum (2006, p. 11) specifically called upon food service providers to “develop, make available, and promote beverage options that help consumers to reduce caloric intake,” including through smaller portion sizes and a range of low-calorie¹³ and zero-calorie beverage choices, increased selections of low-fat and nonfat milk beverages, and pricing strategies that make smaller sizes and lower-calorie options more appealing. Although the beverage industry has sold sugar-sweetened beverages with smaller portion sizes (e.g., 7.5 ounce cans) for some time, they are not priced favorably (CSPI, 2010), nor are they marketed to encourage consumers to choose them in lieu of the larger options (e.g., 12 ounce cans, 20 ounce bottles).

Given the relationship between consumption of sugar-sweetened beverages and child and adolescent overweight and obesity, most policy interventions to date have focused on the elementary and, to a lesser extent, secondary school environments. In 2006, the Alliance for a Healthier Generation (an alliance between the William J. Clinton Foundation and the American Heart Association) brokered an agreement with three major beverage firms to limit access to sugar-sweetened beverages in schools. The resulting School Beverage Guidelines limit portion sizes of and set standards for the calorie and nutrient content of beverages sold in schools; the restrictions are tighter in elementary and middle schools than in high schools. An industry report following implementation of the guidelines indicated an 88 percent reduction in beverage calories shipped to schools by the middle of the 2009-2010 school year (ABA, 2010). Independent researchers reported that based on a nationally representative mail-back survey, high-calorie beverages and beverages not allowed by national guidelines were still available in elementary schools during the 2008-2009 school year. They noted that beverages in schools may be obtained from school stores or vending machines that are outside of formal contracts with beverage suppliers (Turner and Chaloupka, 2010). Additionally, concern has been expressed about the less restrictive guidelines for high schools, where intake of sugar-sweetened beverages occurs more frequently than in other schools; about the lack of nonindustry evaluation funding; and about the fact that the guidelines fail to address other beverages, such as calorie-dense sports drinks, diet drinks (for which brand marketing continues to be offered), and new drink categories such as energy drinks (Sharma et al., 2010).

Levy and colleagues (2011) reviewed the literature on school nutrition policies directed at consumption of sugar-sweetened beverages by children and adolescents, finding that policies limiting the availability of such beverages and improving food offerings in school lunches generally have been associated with reduced consumption of these beverages. In middle schools, restricting access can reduce the percentage of students consuming sugar-sweetened beverages by 25 percent and the energy they consume by 30 percent. In high schools, 30 percent reductions in energy intake were observed among student buyers of sugar-sweetened beverages when access policies were in place.

Briefel and colleagues (2009a,b), Levy and colleagues (2011), and Taber and colleagues (2011) conclude that restrictions on in-school access to sugar-sweetened beverages reduce in-school consumption, and that reduced intake of such beverages in schools is unlikely to be offset by increased consumption outside of schools. Recent experience in Boston public schools confirms that students do not compensate for reduced access to sugar-sweetened beverages by buying those beverages outside of school (Cradock et al., 2011) (see Box 6-2).

BOX 6-2

Case Study of the Impact of Boston Public Schools’ Policy on Consumption of Sugar-Sweetened Beverages. Boston Public Schools instituted a policy in 2004 restricting the sale of sugar-sweetened beverages (soft drinks, non-100 percent fruit and (more...)

Access to water

Recognizing that if governments, employers, schools, public places, and other locations encouraged reduced consumption of sugar-sweetened beverages, consumers would need alternative options readily available, the IOM (2007a, 2009), the National Association of County and City Health Officials (NACCHO, 2010), the Department of Health and Human Services (HHS/USDA, 2010), and CDC (Khan et al., 2009) all recommend increasing the availability of safe, free drinking water and healthier beverages such as non-fat/low-fat milk and 100 percent juices in schools and other places where beverages are sold and served. Increasing water intake may help limit excess weight gain among children, adolescents, and adults (Daniels and Popkin, 2010; Dennis et al., 2010; Stookey et al., 2007, 2008). Replacing sugar-sweetened beverages with water is associated with reductions in total energy intake for children and adolescents (Wang et al., 2009), and installing water fountains in public places and facilities can increase water intake and prevent and reduce overweight and obesity (Muckelbauer et al., 2009). The Healthy, Hunger-Free Kids Act of 2010¹⁴ requires schools participating in federally funded child nutrition programs to make water available during meal periods at no cost to students, and mandates that child care facilities provide free water throughout the day. After a survey revealed that 40 percent of responding California school districts reported lack of access to free drinking water in cafeterias for students, a state law was implemented requiring schools to make free, fresh drinking water available during meals (California Food Policy Advocates, 2011).

Pricing strategies and fiscal policies

At least three IOM committees have considered fiscal policies (taxes and incentives) to discourage consumption of unhealthy foods and beverages such as sugar-sweetened beverages or encourage consumption of healthier alternatives. Two committees (IOM, 2005, 2006b) concluded that evidence was insufficient to draw a definite conclusion or develop a strong recommendation either for or against imposing a tax on less healthful foods. In 2009, however, the IOM recommended that local governments “implement fiscal policies and local ordinances to discourage the consumption of calorie-dense, nutrient poor foods and beverages (e.g., taxes, incentives, land use and zoning regulations)” (IOM, 2009, p. 62). That committee highlighted “implement[ing] a tax strategy to discourage consumption of foods and beverages of minimal nutritional value, such as sugar-sweetened beverages” as an action with considerable promise, noting the growing interest in and broad reach of such a strategy (IOM, 2009, p. 63). One of the earlier IOM committees recommended that governments consider incentives, including tax incentives, to encourage and reward food, beverage, and restaurant companies that develop, provide, and promote healthier beverages for children and adolescents in the settings in which they typically consume beverages (IOM, 2006b). Likewise, the 2009 IOM report recommends creating incentive programs to enable small food store owners in underserved areas to carry healthier, affordable food items. That report also recommends offering incentives or subsidies to government programs and localities that provide healthy foods at competitive prices and limit calorie-dense, nutrient-poor foods.

Non-IOM reports also have recommended fiscal policies to discourage consumption of less healthy foods and beverages and encourage consumption of healthier alternatives. The California Legislature Task Force on Diabetes and Obesity (Greenwood et al., 2009) has recommended creating tax incentive programs to encourage employers to adopt workplace policies that make healthy eating easier for employees, as well as offering incentives to mobile carts within one-half mile of school campuses to offer healthy and restrict unhealthy foods. The Robert Wood Johnson Foundation Action Strategies Toolkit for state and local leaders (RWJF, 2009) encourages state and local policy makers, through financial or other incentives, to motivate restaurants to provide price reductions for healthier foods, and convenience stores and bodegas to provide affordable healthy options. CDC (Khan et al., 2009) has recommended that communities provide incentives for food retailers to locate in underserved areas and offer healthy food and beverage choices. CDC also has issued a series of strategies for reducing consumption of sugar-sweetened beverages. Finally, the White House Task Force on Childhood Obesity (2010) has recommended an analysis of the effect of state and local taxes on less healthy, energy-dense foods.

While available research on existing small sales taxes (ranging from 1.0 to 7.25 percent) (Bridging the Gap Program, 2011) finds little or no impact on consumption, body mass index (BMI), or obesity rates (Finkelstein et al., 2010; Kim and Kawachi, 2006; Powell and Chriqui, 2011; Powell et al., 2009; Sturm et al., 2010), many believe that more sizable, nontrivial pricing interventions could have measurable effects on weight outcomes, particularly for children and adolescents, populations of low socioeconomic status, and those most at risk for overweight (Finkelstein et al., 2010; Powell and Chaloupka, 2009; Powell et al., 2009; Sturm et al., 2010). Although a number of state and local governments recently have attempted to enact sizable taxes on sugar-sweetened beverages (on the order of 1 cent per liquid ounce) (Rudd Center for Food Policy and Obesity, 2011), none have succeeded in doing so to date. The rationale for these proposals is grounded largely in the considerable body of evidence for the impact of food pricing on weight outcomes and in an emerging literature that examines the impact of taxes or price increases (amounting to a 10-20 percent price increase) on consumption of sugar-sweetened beverages and weight outcomes. Note that estimates of the impact of a tax on sugar-sweetened beverages will likely vary because of the length of the causal pathway between prices of these beverages and weight outcomes and the complexity of the variables involved in this pathway.

The effectiveness of a tax on sugar-sweetened beverages depends in part on the degree to which consumers change their food and beverage purchasing and consumption behavior in response to higher sugar-sweetened beverages prices (price elasticity). In a review that includes studies based on large survey data sets, Andreyeva and colleagues (2010) show that food consumption or expenditure is generally price sensitive. Smith and colleagues (2010) estimate that a 10 percent price increase for sweetened beverages would reduce grocery store purchases of these items by 12.6 percent, and also note that when taxes are large, estimated elasticities may underestimate actual consumer reactions. Another study (Wendt and Todd, 2011) reports that inflation-adjusted prices for carbonated drinks have fallen over the past 30 years and that responses to changes in price vary, particularly across income levels and BMI range. In the past, 10 percent higher prices for carbonated beverages were associated with a decrease in the average child’s BMI. The effect was significant for boys but not for girls. The effect also was greater for children in households with income below 200 percent of the federal poverty level, a finding that is not surprising because economic theory suggests that lower-income households are more price-responsive than their higher-income counterparts. The effect was larger for children with lower BMI, perhaps because these children are less likely to substitute caloric drinks (such as juice) (see the discussion below) or because their preferences for carbonated beverages are less entrenched, so their price sensitivity for these beverages is higher. Notwithstanding available estimates, Smith and colleagues (2010) conclude that the literature lacks the demand elasticity estimates needed to fully examine the effect of a tax on sugar-sweetened beverages in practice.

A number of studies have predicted the effect of sizable taxes and/or price increases on consumption of sugar-sweetened beverages. According to one recent estimate, a 10 percent price increase for soft drinks would reduce their consumption by 8-10 percent (Andreyeva et al., 2010). Another analysis indicates that a penny-per-ounce tax would reduce per capita consumption of sugar-sweetened beverages by 24 percent and could reduce per capita calorie intake from such beverages by about 50 calories/day (approximately 5 pounds/year), assuming no substitution of other caloric beverages or foods (Andreyeva et al., 2011). Some of these same studies suggest that a 20 percent increase in the price of sugar-sweetened beverages or a penny-per-ounce tax could significantly reduce per capita calorie intake, translating to a reduction in body weight ranging from approximately 1.5 to 5.0 pounds a year, assuming no substitution of other caloric beverages (Andreyeva et al., 2011; Dharmasena and Capps, 2011; Smith et al., 2010). Chaloupka and colleagues (2011b) modeled a penny-per-ounce tax on sugar-sweetened beverages in the state of Illinois, showing that the frequency of consumption of such beverages (>2 times/day) would fall sharply as a result of the tax. They estimated an overall 23.5 percent drop in consumption of sugar-sweetened beverages and an average weight reduction of 1.7 pounds annually based on the assumption that half of the calorie deficit from reduced consumption of such beverages would be offset by increases in energy intake from other sources. Wang and colleagues (2012) estimated that a penny-per-ounce sugar-sweetened beverages tax would reduce sugar-sweetened beverages consumption by 15 percent among adults aged 25-64, after factoring in the assumption that 40 percent of the calorie deficit from reduced sugar-sweetened beverages consumption would be compensated for by consumption of other caloric beverages (such as milk and juice) in equal measure. They also projected the sugar-sweetened beverages tax’s impact on downstream health benefits and medical costs savings over a 10-year period (2010-2020), finding that it could reduce new cases of type 2 diabetes by 2.6 percent and the prevalence of obesity by 1.5 percent. Over 10 years these reductions would result in 95,000 fewer coronary heart events, 8,000 fewer strokes, and 26,000 fewer premature deaths, avoiding more than $17 million in medical costs while generating approximately $13 billion in tax revenue.

The extent to which calories from nontaxed foods and caloric beverages are substituted for calories in taxed items is a key consideration when translating tax-induced reductions in caloric intake into decreased body weight and obesity (Chaloupka et al., 2011b). The literature in this area is mixed. Fletcher and colleagues (2011b) maintain that substitution of other high-calorie drinks for soft drinks may blunt the effect of soft drink taxes on obesity; they cite the lack of evidence supporting the argument that if taxes are large enough, consumption of sugar-sweetened beverages will fall substantially. However, others have estimated only modest increases in calories from other caloric beverages and continue to observe a net caloric deficit when examining a hypothetical 20 percent price increase in sugar-sweetened beverages (Dharmasena and Capps, 2011; Smith et al., 2010). While those researching this topic agree almost universally that more research is needed, Fletcher and colleagues (2011a) point out that convincing evidence may not be available until a large tax is instituted in a state or locality. Despite the apparent lack of research examining substitution effects, analyses that examine weight outcomes are implicitly capturing the substitution that occurs, and a negative impact of taxing sugar-sweetened beverages on BMI and/or obesity prevalence indicates that full compensation from substitution of other calorie sources does not occur.

The committee considered the potential allegation that taxes on sugar-sweetened beverages are regressive, that is, that they would disproportionately affect low-income and minority consumers, who spend a larger proportion of their income on food than those with higher incomes and whites. Brownell and colleagues (2009) observe that taxes on such beverages may be most beneficial to the former populations because they are disproportionately affected by obesity, may consume more soft drinks than other populations, and may be more price sensitive—all supporting the argument that they may stand to benefit substantially from reduced consumption of sugar-sweetened beverages, especially if they are the focus of the obesity prevention programs funded by the taxes on these beverages. Furthermore, sugar-sweetened beverages are not an essential dietary component, and as explained above, hinder Americans from achieving dietary intakes aligned with the Dietary Guidelines for Americans. Finally, water, a no-cost alternative to sugar-sweetened beverages, is readily available (Brownell et al., 2009).

Even though predicted reductions in body weight resulting from a substantial tax on sugar-sweetened beverages may be relatively small or still must be tested in practice, the committee believes that fiscal policies such as incentivizing the purchase of healthier beverages or taxing sugar-sweetened beverages are one action that can be taken to reduce consumption of these beverages. The current evidence does not indicate that fiscal policies alone can solve the obesity problem. Rather, it suggests that fiscal policies would act synergistically with other actions to reduce consumption of sugar-sweetened beverages, thereby advancing the achievement of a comprehensive obesity prevention strategy, particularly if the revenues from taxes on such beverages were directed toward obesity prevention programs, as recommended by the public health community (Brownell and Ludwig, 2011; Chaloupka et al., 2011a; Powell and Chriqui, 2011). The public also is more supportive of taxes on sugar-sweetened beverages if revenues will support activities to reduce obesity. A December 2008 poll found that 52 percent of New Yorkers supported a “soft drink tax,” and support increased to 72 percent when respondents were told the revenues would be earmarked to prevent obesity and to avoid service cuts in schools, health care, mass transit, or law enforcement (Citizens’ Committee for Children of New York, Inc., 2008). Likewise, a 2011 poll of 500 Massachusetts voters found that 69 percent would support a sales tax on soda if the revenues funded local schools or anti-obesity programs targeting children, but the sample was split nearly 50-50 if they were not told how the revenues would be used. The Rudd Center has compiled additional results from eight other polls demonstrating public support for a tax on sugar-sweetened beverages, particularly when the revenues would be earmarked for obesity prevention (Rudd Center for Food Policy and Obesity, 2010).

Social marketing campaigns

Social marketing has been used to impact a variety of health and risk behaviors among children, adolescents, and adults. Because many health-based social marketing campaigns are insufficiently funded and not sustained over significant periods of time, assessing their effectiveness accurately is difficult (Randolph and Viswanath, 2004; Wakefield et al., 2010). However, evidence from carefully designed studies indicates that media campaigns can have a positive impact on health behaviors if they are carefully crafted, well tested, fully funded, highly targeted (in terms of audience and behavior), and sustained over a long period of time (Wakefield et al., 2010). Social marketing campaigns are discussed in greater detail in Chapter 7, under Strategy 3-1.

Social marketing campaigns aimed at reducing consumption of sugar-sweetened beverages are emerging rapidly and are encouraged by health professional organizations. For example, the American Academy of Pediatric Dentistry “encourages collaboration with other dental and medical organizations, governmental agencies, education officials, parent and consumer groups, and corporations to increase public awareness of the negative effects of frequent and/or inappropriate intake of sweetened drinks (carbonated and noncarbonated) and low nutrient dense snack foods on infant, child, and adolescent oral health, nutrition, and general health” (AAPD, 2010, p. 56).

In 2011, a campaign titled “Life’s Sweeter with Fewer Sugary Drinks” debuted with the goal of decreasing average consumption of such drinks (regular soda, fruit drinks with less than 100 percent juice, sweetened teas, lemonade, energy drinks, and sports drinks) to approximately three cans per person per week by 2020 (CSPI, 2011). The campaign brings together health experts, civic organizations, youth groups, and others to meet this goal. It also encourages employers, hospitals, and government agencies to adopt policies designed to decrease soda consumption. The campaign has been embraced by the American Diabetes Association, the American Heart Association, the Center for Science in the Public Interest, and more than 100 local and national health organizations. At the same time, local and state governments from across the country—including Boston, New York City, Philadelphia, Seattle and King County, and the Rhode Island Department of Health, to name a few—have been developing and implementing social marketing campaigns aimed at reducing consumption of sugar-sweetened beverages.

Role of health care providers

All health care providers should adopt standards of practice for prevention, screening, and counseling regarding overweight and obesity to help their patients achieve and maintain a healthy weight (see Chapter 8, Strategy 4-1). Given the linkage between consumption of sugar-sweetened beverages and obesity, particularly among children and adolescents, and the fact that these beverages are the leading source of added sugars in the American diet, health care providers such as physicians, dentists, registered dietitians, and nurses have a unique opportunity to screen and/or counsel patients on the risks associated with overconsumption of these beverages. The American Academy of Pediatrics (2011) calls for pediatricians to educate children, adolescents, and their parents about the linkage among consumption of sports drinks, excess caloric intake, and obesity and overweight, as well as dental erosion; to promote water as the principal source of hydration for children and adolescents; and to limit consumption of sports drinks to circumstances in which rapid replenishment of carbohydrates and/or electrolytes is necessary, such as during periods of prolonged, vigorous physical activity. Additionally, given the risk of dental caries associated with excessive sugar consumption, the AAP Section on Pediatric Dentistry and Oral Health (2008) recommends that pediatricians counsel parents and caregivers on the importance of reducing children’s exposure to added sugars in foods and beverages, including limiting sugared drinks, avoiding carbonated beverages and juice drinks containing less than 100 percent juice, and encouraging children to drink only water and milk between meals.

In summary, sugar-sweetened beverages make a substantial contribution to the energy intake of Americans and are linked to increased weight gain/body weight, particularly in children. Moreover, availability of and exposure to such beverages are widespread in all sectors of society. Therefore, the committee believes an integrated, comprehensive approach will be needed to cause Americans to reduce consumption of these beverages as part of an effort to ensure a balanced diet that includes a variety of foods and beverages recommended in the Dietary Guidelines for Americans.

Indicators for Assessing Progress in Obesity Prevention for Strategy 2-1

Primary Indicator

• Reduction in energy intake from consumption of sugar-sweetened beverages.Source for measuring indicator: NHANES

Process Indicators

• Reduction in consumption of sugar-sweetened beverages such that they account for a smaller proportion of solid fats and added sugars in the daily diet. Source for measuring indicator: NHANES
• Adoption by states and school districts of policies that prohibit the sale of sugar-sweetened beverages in schools and require that schools offer a variety of no- or low-calorie beverage options that are favorably priced.Sources for measuring indicator: CDC’s School Health Policies and Practices Survey and CLASS (NCI)
• Adoption by states and school districts of policies that require schools to provide access to free, clean, potable water throughout the school setting.Source for measuring indicator: CDC’s School Health Policies and Practices Survey

Foundational Indicators

• USDA’s prohibition of the sale of sugar-sweetened beverages in schools as part of the competitive food and beverage regulations to be developed for the Healthy, Hunger-Free Kids Act of 2010.Source for measuring indicator: USDA
• Reduction in energy intake from consumption of sugar-sweetened beverages among populations with higher rates of consumption of such beverages, including non-Hispanic blacks, Mexican Americans, and lower-income individuals. Source for measuring indicator: NHANES

NOTE: CDC = Centers for Disease Control and Prevention; CLASS = Classification of Laws Associated with School Students; NCI = National Cancer Institute; NHANES = National Health and Nutrition Examination Survey; USDA = U.S. Department of Agriculture.

Strategy 2-3. Utilize Strong Nutritional Standards for all Foods and Beverages Sold or Provided Through the Government, and Ensure That These Healthy Options Are Available in All Places Frequented by the Public

Government agencies (federal, state, local, and school district) should ensure that all foods and beverages sold or provided through the government are aligned with the age-specific recommendations in the current Dietary Guidelines for Americans. The business community and the private sector operating venues frequented by the public should ensure that a variety of foods and beverages, including those recommended by the Dietary Guidelines for Americans, are sold or served at all times.

For government agencies, potential actions include

• the federal government expanding the healthy vending/concession guidelines to include all government-owned and/or -operated buildings, worksites, facilities,¹⁵ and other locations where foods and beverages are sold/served; and
• all state and local government-owned and -operated buildings, worksites, facilities, and other locations where foods and beverages are sold/served (including through vending machines and concession stands) adopting and implementing a healthy food and beverage vending/concession policy.

For the business community/private sector, potential actions include

• the business community and private-sector entities that operate places frequented by the public ensuring that a variety of food and beverage options are competitively priced and available for purchase and consumption in these places,¹⁶ including food and beverages that are aligned with the recommendations of the Dietary Guidelines for Americans.

Implementation

Federal, state, and local government

Federal, state, and local government agencies are providers of food and should not be overlooked as part of the food environment. Various government programs procure food for their own restaurant/food service operations or provide assistance to allow others to do so (IOM, 2010). These programs range from food purchases for public worksites, health care facilities, senior centers, and military bases to foods sold in vending machines in city parks and other public places. More than 19 million individuals are employed at the federal, state, and local levels of government (U.S. Census Bureau, 2007), and this figure does not include members of the public who frequent or reside in government-owned or operated buildings, worksites, or facilities. Further, more than 1,400,000 people are on active duty in the U.S. military worldwide (Defense Manpower Media Center, 2011); the most recent estimate indicates that the military purchases more than $800 million in food to feed these personnel (GAO, 2000). According to the U.S. Census Bureau, between 2005 and 2009 more than 2 million people resided in adult correctional facilities, more than 1.8 million in nursing facilities/skilled nursing facilities, and more than 2 million in college/university housing (U.S. Census Bureau, 2011). Additionally, a number of federal programs use government funds for the purchase of food (GAO, 2000). The ability of these settings to institute public food standards may vary given their purpose, operating constraints, and reach (see Table 6-2).

TABLE 6-2

Federal Agencies and Programs That Directly Purchase Foods or Use or Set Standards for Food Purchases.

Early child care and school settings also are key points of food access. More than 8 million children aged 3-5 were enrolled in early child care programs in 2009, and more than 55 million children and adolescents were projected to be enrolled in public and private secondary schools in 2010 (NCES, 2010, 2011). (See the discussion of school food standards in Chapter 9.)

Research has shown that changes in the workplace and child care settings (in addition to changes in the school setting addressed in Recommendation 5 [ Chapter 9]) are effective in increasing the consumption of healthy options or in limiting access to unhealthy options. Strong evidence shows that worksite obesity prevention and control programs can reduce weight in employees and create habits that could be modeled at home. Some of these effective programs include interventions that improve access to healthy foods by changing cafeteria and vending machine options as part of a multicomponent program (Anderson et al., 2009). (See also the discussion of Strategy 4-3 in Chapter 8.) Likewise, research suggests that in child care settings, the nutritional quality of meals and snacks can be poor, and activity levels may be inadequate (see the discussion of Strategy 1-4 in Chapter 5) (Ball et al., 2008; Padget and Briley, 2005; Story et al., 2006). Furthermore, children model the behavior of adults (Pearson et al., 2009). Thus, ensuring that publicly run worksites and child care centers are offering foods and beverages that are aligned with the Dietary Guidelines for Americans is essential to making the healthy choice the default choice (IOM, 2009; Ritchie et al., 2012).

Governments nationwide are in fact adopting and implementing nutrition standards to ensure the availability of a wide variety of foods and beverages, including those recommended by the Dietary Guidelines for Americans, in government-run or -regulated facilities and programs and applying those standards to food and beverage procurement and contracting (see Box 6-3). Such standards were recommended by a prior IOM committee and other experts (IOM, 2009, 2011). They build on the work done in schools nationwide to create healthy eating environments through state, district, and federal policies (the latter with the implementation of the Healthy, Hunger-Free Kids Act of 2010¹⁷) that restrict fats, sugars, calories, and other items that the Dietary Guidelines recommend limiting (CDC, 2011; Chriqui et al., 2010; Trust for America’s Health and RWJF, 2011).

BOX 6-3

Government Nutrition Standards. A number of states, counties, and cities have adopted nutrition standards for the meals and snacks they serve or provide to clients, employees, and the public. The introduction of nutrition standards for snacks and drinks (more...)

By instituting nutrition standards for all foods purchased with government dollars, local and state authorities can reduce the calories consumed by their residents across a variety of environments, model healthier eating, and potentially drive reformulation as companies respond to new product specifications. Furthermore, local and state governments can have considerable influence over a number of diverse food purchase and distribution locations. The introduction of nutrition standards is an area of increasing activity that offers an opportunity to influence diet at the population level. Beyond federal programs, state and local governments often are relatively large purchasers of food. They purchase or contract with restaurant/food service operators to supply the foods sold in employee cafeterias, schools and child care centers, public hospitals, senior centers, parks, and numerous other facilities (IOM, 2010).

Business community

Foods are readily available in public places such as movie theaters, sports venues, and theme parks, to name a few, and attendance at these public places is not trivial. In 2010, more than 1.3 billion movie tickets were sold in the United States and Canada; 68 percent of all Americans and Canadians—or 222.7 million people—attended at least one movie in 2010 (Motion Picture Association of America, 2010). Furthermore, 339 million people attended theme parks during 2009, and 132 million attended professional sporting events such as Major League Baseball, National Football League, and National Basketball Association games—all venues where food is sold for immediate consumption and all hosting a captive audience or consumer base seeking a wide range of food and beverage options, including those recommended by the Dietary Guidelines for Americans (Motion Picture Association of America, 2010). Indeed, the business community has been improving the foods and beverages offered for sale at entertainment and sporting events (see Box 6-4 for examples).

BOX 6-4

Examples of Improved Food and Beverage Offerings at Entertainment and Sporting Events. Improvements in food and beverage offerings are not limited to government settings. Positive steps in this regard also are occurring in the business community through (more...)

In sum, the committee believes that implementation of this strategy, in concert with the other strategies recommended in this chapter and in the report as a whole, represents an important step toward reducing the obesogenic environment in which Americans live, work, and play. Implementation of this strategy by governments and the business community would go a long way toward providing Americans with access to foods and beverages recommended by the Dietary Guidelines for Americans in places where they spend their work and leisure time.

Indicators for Assessing Progress in Obesity Prevention for Strategy 2-3

Primary Indicators

• Increase in the proportion of energy intake attributable to consumption of foods and beverages recommended by the Dietary Guidelines for Americans.Source for measuring indicator: NHANES
• Reduction in energy intake associated with solid fats and added sugars. Source for measuring indicator: NHANES

Process Indicators

• The federal government’s expansion of its healthy vending/concession guidelines to include all federal government-owned, -operated, and -occupied buildings, worksites, and facilities.Sources for measuring indicator: GSA and HHS
• Increase in the proportion of states and municipalities that adopt and implement policies designed to ensure that foods/beverages sold and served in government-owned and -operated buildings, worksites, and facilities and other public places where foods and beverages are sold/served are aligned with the recommendations of the Dietary Guidelines for Americans.Source needed for measurement of indicator.
• Increase in the proportion of public places where foods and beverages are sold that offer a range of affordable and healthy food and beverage options.Source needed for measurement of indicator.
• Assurance of age-appropriate portion sizes and increase in quality of foods and beverages offered in government-owned and/or -operated child care programs.Source for measuring indicator: USDA program monitoring/reporting for funded programs

Foundational Indicator

• Adoption of healthy vending and food/beverage standards by members of the business community selling foods/beverages for public consumption.Source needed for measurement of indicator.

NOTE: GSA = U.S. General Services Administration; HHS = U.S. Department of Health and Human Services; NHANES = National Health and Nutrition Examination Survey; USDA = U.S. Department of Agriculture.

Strategy 2-4. Introduce, Modify, and Utilize Health-Promoting Food and Beverage Retailing and Distribution Policies

States and localities should utilize financial incentives such as flexible financing or tax credits, streamlined permitting processes, and zoning strategies, as well as cross-sectoral collaborations (e.g., among industry, philanthropic organizations, government, and the community) to enhance the quality of local food environments, particularly in low-income communities. These efforts should include encouraging or attracting retailers and distributors of healthy food (e.g., supermarkets) to locate in underserved areas and limiting the concentration of unhealthy food venues (e.g., fast-food restaurants, convenience stores). Incentives should be linked to public health goals in ways that give priority to stores that also commit to health-promoting retail strategies (e.g., through placement, promotion, and pricing).

Potential actions include

• states creating cross-agency teams to analyze and streamline regulatory processes and create tax incentives for retailing of healthy foods in underserved neighborhoods;
• states and localities creating cross-sectoral collaborations among the food and beverage industry, philanthropy, the finance and banking sector, the real estate sector, and the community to develop private funding to facilitate the development of healthy food retailing in underserved areas; and
• localities utilizing incentive tools to attract retailing of healthy foods (e.g., supermarkets and grocery stores) to underserved neighborhoods, such as through flexible financing or tax credits, streamlined permitting processes, zoning strategies, grant and loan programs, small business/economic development programs, and other economic incentives.

Implementation

A number of efforts have been undertaken to support and implement the sentiment of this recommended strategy by developing programs, initiatives, and legislation through public and private partnerships. The introduction of supermarkets in neighborhoods where they are lacking has yielded some initial positive economic results (see Box 6-5 for an example of supermarket initiatives and support programs).

BOX 6-5

Supermarket Programs, Initiatives, and Legislation. The Food Trust’s Supermarket Campaign Pennsylvania Fresh Food Financing Initiative

Given the disproportionate lack of access to affordable healthy foods for a large number of Americans, the use of financial incentives, zoning, and cross-sectoral collaborations can attract healthy food retailing and distribution (e.g., supermarkets) to underserviced areas and limit the concentration of unhealthy food venues (e.g., fast food). Preliminary economic impact assessments of such initiatives have found that they have a significant impact on estate prices, employment, and earnings, and they are expected to significantly increase access to healthy foods for millions of households and communities that are currently underserved (The Reinvestment Fund, 2010; Treuhaft and Karpyn, 2010). Yet while a large number of initiatives and investments are already being implemented in some localities, it is clear that further work is needed to provide access to healthy foods for everyone. In 2011, leaders from major retailers, foundations, and small businesses announced commitments to provide access to healthy, affordable food for millions of people in underserved communities (Partnership for a Healthier America, 2011). As part of the retail industry’s focus on healthy food initiatives, some of these same retailers have reported undertaking large-scale efforts to encourage healthier food purchases by understanding their customers and meeting their needs through the use of pricing strategies (e.g., coupons, daily specials), simple labeling or endorsements of healthier food products, in-store cooking demonstrations and recipes, and reorganization of the supermarket itself (customers must walk through the produce area to get to other sections of the store) (Rogers, 2011; Thomas, 2011).

In sum, the committee believes this recommended strategy would likely have a direct effect on the availability and accessibility of healthy and unhealthy foods in targeted neighborhoods and could encourage consumers to purchase foods that would help them meet the Dietary Guidelines for Americans. In particular, this strategy has the potential to reduce disparities in obesity rates for consumers who have no or limited access to retailers of healthy foods (e.g., supermarkets) and are exposed to a large number of retailers of unhealthy food. These include residents of neighborhoods that are predominantly black, Hispanic, low-income, and rural, as well as individuals lacking transportation.

Indicators for Assessing Progress in Obesity Prevention for Strategy 2-4

Process Indicators

• Increase in the proportion of Americans who have access to a food retail outlet that sells a variety of foods recommended by the Dietary Guidelines for Americans. Source needed for measurement of indicator.
• Adoption and achievement of the grocery industry standard of 3 square feet of retail space per capita by all grocery retailers.^* Source needed for measurement of indicator.

Foundational Indicator

• Development and implementation by municipal governments of incentive programs for new and/or existing food retailers to increase access to healthier food and beverage options in underserved areas.Source needed for measurement of indicator.

*

Three square feet of space per person is a measure of demand for grocery retail service in a defined area commonly used by grocery retailers (International Council of Shopping Centers, 2008).

Strategy 2-5. Broaden the Examination and Development of U.S. Agriculture Policy and Research to Include Implications for the American Diet

Congress, the Administration, and federal agencies should examine the implications of U.S. agriculture policy for obesity, and should ensure that such policy includes understanding and implementing, as appropriate, an optimal mix of crops and farming methods for meeting the Dietary Guidelines for Americans.

Potential actions include

• the President appointing a Task Force on Agriculture Policy and Obesity Prevention to evaluate the evidence on the relationship between agriculture policies and the American diet, and to develop recommendations for policy options and future policy-related research, specifically on the impact of farm subsidies and the management of commodities on food prices, access, affordability, and consumption;
• Congress and the Administration establishing a process by which federal food, agriculture, and health officials would review and report on the possible implications of U.S. agriculture policy for obesity prevention to ensure that this issue will be fully taken into account when policy makers consider the Farm Bill;
• Congress and the U.S. Department of Agriculture (USDA) developing policy options for promoting increased domestic production of foods recommended for a healthy diet that are generally underconsumed, including fruits and vegetables and dairy products, by reviewing incentives and disincentives that exist in current policy;
• as part of its agricultural research agenda, USDA exploring the optimal mix of crops and farming methods for meeting the current Dietary Guidelines for Americans, including an examination of the possible impact of smaller-scale agriculture, of regional agricultural product distribution chains, and of various agricultural models from small to large scale, as well as other efforts to ensure a sustainable, sufficient, and affordable supply of fresh fruits and vegetables; and
• Congress and the Administration ensuring that there is adequate public funding for agricultural research and extension so that the research agenda can include a greater focus on supporting the production of foods Americans need to consume in greater quantities according to the Dietary Guidelines for Americans.

INTEGRATION OF STRATEGIES FOR ACCELERATING PROGRESS IN OBESITY PREVENTION

The strategies included in this chapter have one goal: to make the healthy option the routine and affordable option. Increasing access to healthy food and beverage options recommended by the Dietary Guidelines for Americans (HHS/USDA, 2010) and decreasing consumption of solid fats and added sugars (e.g., sugar-sweetened beverages), in particular, are critical steps toward achieving energy balance when implemented in concert with achieving recommended levels of physical activity ( Chapter 5). However, adherence to the food patterns recommended by the Dietary Guidelines for Americans is no easy task and will take time. The current obesogenic environment provides unhealthy options that are often more affordable and available than healthy options. For this situation to change, a concerted effort will be required on the part of governments, industry, restaurants and other food service providers, schools and child care providers, and members of the business community/private sector operating places frequented by the public to change the types of foods and beverages sold or offered to consumers such that they provide a range of competitively priced options.

Governments, in particular, have a critical role to play in this effort. Through their policy-making authority, governments (at all levels) can incentivize the purchase of healthier food and beverage options or impose taxes on unhealthy options (e.g., sugar-sweetened beverages). State and local governments also can remove regulatory barriers to and create incentives for retailing of healthy foods, particularly in underserved neighborhoods without ready access to healthy food options. Governments should support the work of community groups and coalitions in their efforts to create healthy food environments in the nation’s communities. And the federal government should examine the extent to which U.S. farm policy can support production of the optimal mix of crops and the farming methods necessary to meet the food patterns recommended in the Dietary Guidelines for Americans.

In short, the strategies presented in this chapter are intended to support the evidence-based recommendations included in the Dietary Guidelines for Americans. Taken in isolation, the individual strategies included in this chapter likely will be insufficient to accelerate progress in obesity prevention. Taken together, however, in concert with comparable changes in physical activity levels, in school environments, in messaging, in health care and worksite environments, and in critical community supports, these strategies can go a long way toward helping Americans meet the food patterns recommended by the Dietary Guidelines for Americans and, in turn, accelerate progress in obesity prevention.

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Footnotes

8

Sugar-sweetened beverages are defined to include all beverages containing added caloric sweeteners, including, but not limited to, sugar- or otherwise calorically sweetened regular sodas, less than 100 percent fruit drinks, energy drinks, sports drinks, and ready-to-drink teas and coffees.

9

This figure is calculated by summing all persons’ mean intake of energy (in kilocalories) from two categories—soda/energy/sports drinks (114 kcal) and fruit drinks (36 kcal)—to obtain 150 kcal, which is a higher proportion of total calories than that represented by any other food group. This is likely a conservative estimate, because it does not include calories from other sugar-sweetened beverages, such as sweetened, ready-to-drink teas and coffee drinks (NCI, 2010b).

10

This figure is calculated by summing all persons’ mean intake of added sugars (in teaspoons) from two categories—soda/energy/sports drinks (35.7 tsp) and fruit drinks (10.5 tsp)—which yields a higher proportion of added sugars than that represented by any other food group (NCI, 2010a).

11

The Keystone Forum of the Keystone Center is a nonprofit public policy and dispute resolution organization that brought together participants from industry, government, civic organizations, and academia.

12

The American Academy of Pediatrics (AAP) recommends not introducing 100 percent fruit juice into the diet before 6 months of age, and recommends daily upper limits of 4-6 ounces for children aged 1-6 and 8-12 ounces for older children, up to age 18 (AAP Committee on Nutrition, 2001).

13

Because its charge was to focus specifically on strategies for accelerating progress in obesity prevention, the committee did not deliberate on the effects of low-calorie, artificially sweetened beverages on population health and did not take a position on this issue.

14

Public Law 111-296, 111th Cong., 2d sess. (December 13, 2010), 124, 3183.

15

Government-owned and -operated buildings, worksites, and facilities” is defined broadly to include not only places of work but also locations such as government-owned and/or -operated child care centers, hospitals, and other health care/assisted living facilities, military bases, correctional facilities, and educational institutions.

16

Places frequented by the public” includes, but is not limited to, privately owned and/or operated locations frequented by the public such as movie theaters, shopping centers, sporting and entertainment venues, bowling alleys, and other recreational/entertainment facilities.

17

Public Law 111-296 (December 13, 2010).

18

See http://aic​.ucdavis.edu/obesity/papers​.htm (accessed October 19, 2011).

19

See http://healthyfoodaction.org/?q=hero/what-it-takes-grow-healthy-food-views-farm (accessed December 12, 2011).