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Food and Beverage Environments

Food and Beverage Environments: Goal, Recommendation, Strategies, and Actions for Implementation

Goal: Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice.

Recommendation 2: Governments and decision makers in the business community/private sector1 should make a concerted effort to reduce unhealthy food and beverage options2 and substantially increase healthier food and beverage options at affordable, competitive prices.

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1The business community/private sector includes private employers and 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.

2Although there is no consensus on the definition of “unhealthy” foods/beverages, the term refers in this report to foods and beverages that are calorie-dense and low in naturally occurring nutrients. Such foods and beverages contribute little fiber and few essential nutrients and phytochemicals, but contain added fats, sweeteners, sodium, and other ingredients. Unhealthy foods and beverages displace the consumption of foods recommended in the Dietary Guidelines for Americans and may lead to the development of obesity.



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6 Food and Beverage Environments Food and Beverage Environments: Goal, Recommendation, Strategies, and Actions for Implementation Goal: Create food and beverage environments that ensure that healthy food and beverage options are the routine, easy choice. Recommendation 2: Governments and decision makers in the business community/private sector1 should make a concerted effort to reduce unhealthy food and bever­ age options2 and substantially increase healthier food and beverage options at affordable, competitive prices. 1 The business community/private sector includes private employers and 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. 2 Although there is no consensus on the definition of “unhealthy” foods/beverages, the term refers in this report to foods and beverages that are calorie-dense and low in naturally occur- ring nutrients. Such foods and beverages contribute little fiber and few essential nutrients and phytochemicals, but contain added fats, sweeteners, sodium, and other ingredients. Unhealthy foods and beverages displace the consumption of foods recommended in the Dietary Guidelines for Americans and may lead to the development of obesity. 153

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Strategy 2-1: Adopt policies and implement practices to reduce over- consumption 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 over- consumption of sugar-sweetened beverages.3 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 organiza- tions, 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 spe- cific excise taxes on sugar-sweetened beverages (e.g., cents per ounce of liquid, cents per teaspoon of added sugar), with the revenues being dedi- cated to obesity prevention programs; 3 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. Accelerating Progress in Obesity Prevention 154

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• 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. Strategy 2-2: Increase the availability of lower-calorie and healthier food and beverage options for children in restaurants. Chain and quick- service restaurants should substantially reduce the number of calories served to children and substantially expand the number of affordable and competitively priced healthier options available for parents to choose from in their facilities. Potential actions include • developing a joint effort (modeled after the Healthy Weight Commitment initiative) to set a specific goal for substantially reducing the total annual calories served to children in these facilities; and • ensuring that at least half of all children’s meals are consistent with the food and calorie guidelines of the Dietary Guidelines for Americans for moderately active 4- to 8-year-olds and are competitively priced. 155 Food and Beverage Environments

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Strategy 2-3: Utilize strong nutritional standards for all foods and bev- erages 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 guide- lines to include all government-owned and/or -operated buildings, worksites, facilities,4 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 fre- quented by the public ensuring that a variety of food and beverage options are competitively priced and available for purchase and consumption in 4 “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. Accelerating Progress in Obesity Prevention 156

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these places,5 including foods and beverages that are aligned with the rec- ommendations of the Dietary Guidelines for Americans. 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 collabora- tions (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 under- served 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 under- served 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 facili- tate 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 devel- opment programs, and other economic incentives. 5 “Placesfrequented 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, sport- ing and entertainment venues, bowling alleys, and other recreational/entertainment facilities. 157 Food and Beverage Environments

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Strategy 2-5: Broaden the examination and development of U.S. agricul- ture policy and research to include implications for the American diet. Congress, the Administration, and federal agencies should examine the implica- tions 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 impli- cations 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 recom- mended for a healthy diet that are generally underconsumed, including fruits and vegetables and dairy products, by reviewing incentives and dis- incentives 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. Accelerating Progress in Obesity Prevention 158

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T he 2010 Dietary Guidelines for Americans provide science-based recommenda- tions that Americans aim to maintain energy balance so as to achieve and sus- tain a healthy weight; emphasize nutrient-dense foods and beverages in their diets; and reduce their intake of excess calories, such as those attributable to added sugars and solid fats (as described in Appendix B) (HHS/USDA, 2010). To achieve these dietary goals, the guidelines identify specific foods to increase and others to reduce (Box 6-1). Among the consumer behaviors that the Dietary Guidelines suggest to help Americans achieve these goals are to (HHS/USDA, 2010) • consume foods and drinks to meet, not exceed, calorie needs; • limit calorie intake from solid fats and added sugars; • increase intake of fruits, vegetables, and whole grains; • increase intake of fat-free or low-fat milk and milk products and replace higher-fat milk and milk products with lower-fat options; • choose water, fat-free milk, 100 percent fruit juice, or unsweetened tea or coffee as drinks instead of sugar-sweetened beverages; • choose a variety of foods from protein sources; • consume fewer foods and beverages high in solid fats, added sugars (includ- ing sugar-sweetened beverages), and sodium; • reduce intake of refined grains; • reduce portion sizes; and • cook and eat more meals at home rather than eating out and, when eating out, consider choosing healthier options. Nutrients that the Dietary Guidelines direct Americans to reduce, such as trans and saturated fatty acids, sodium, and added sugars, are often added to foods dur- ing processing. Processing also may result in an increase in caloric density and the removal of beneficial nutrients, such as fiber (Ludwig, 2011). While processing of many foods in this way is intended in part to increase their palatability, some have suggested that it has unintended consequences, in that some of the biologi- cal mechanisms that help us monitor and control the consumption of calories are bypassed. The result is said to be an “addictive consumption” of food that leads to dependence, with physiological symptoms upon withdrawal (Blumenthal and Gold, 2010; Garber and Lustig, 2011; Gearhardt et al., 2011; Ifland et al., 2009; Lenoir et al., 2007). While this line of reasoning is speculative, it is likely that 159 Food and Beverage Environments

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BOX 6-1 Dietary Guidelines Recommendations for Foods to Increase and to Reduce Foods and Nutrients to Increase • Increase vegetable and fruit intake. • Eat a variety of vegetables, especially dark-green and red and orange vegetables and beans and peas. • Consume at least half of all grains as whole grains. Increase whole-grain intake by replacing refined grains with whole grains. • Increase intake of fat-free or low-fat milk and milk products, such as milk, yogurt, cheese, or fortified soy beverages. • Choose a variety of protein foods, which include seafood, lean meat and poultry, eggs, beans and peas, soy products, and unsalted nuts and seeds. • Increase the amount and variety of seafood consumed by choosing seafood in place of some meat and poultry. • Replace protein foods that are higher in solid fats* with choices that are lower in solid fats and calories and/or are sources of oils. • Use oils to replace solid fats* where possible. • Choose foods that provide more potassium, dietary fiber, calcium, and vitamin D, which are nutrients of concern in American diets. These foods include vegetables, fruits, whole grains, and milk and milk products. *Fats with a high content of saturated and/or trans fatty acids, which are usually solid at room tem- perature. Common examples of solid fats include butter, beef fat, lard, shortening, coconut oil, palm oil, and milk fat, which is solid at room temperature but is suspended in fluid milk by homogeniza- tion (HHS/UDSA, 2010). Accelerating Progress in Obesity Prevention 160

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Foods to Reduce • Reduce daily sodium intake to less than 2,300 milligrams (mg) and further reduce intake to 1,500 mg among persons who are 51 and older and those of any age who are black or have hypertension, diabetes, or chronic kidney disease. The 1,500 mg recommendation applies to about half of the U.S. population, including children and the majority of adults. • Consume less than 10 percent of calories from saturated fatty acids by replacing them with monounsaturated and polyunsaturated fatty acids. • Consume less than 300 mg per day of dietary cholesterol. • Keep trans fatty acid consumption as low as possible by limiting foods that con- tain synthetic sources of trans fats, such as partially hydrogenated oils, and by limiting other solid fats. • Reduce the intake of calories from solid fats and added sugars. • Limit the consumption of foods that contain refined grains, especially refined grain foods that contain solid fats, added sugars, and sodium. • If alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and two drinks per day for men—and only by adults of legal drinking age. SOURCE: HHS/USDA, 2010. 161 Food and Beverage Environments

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reductions in the degree of processing would result in diets more likely to meet the Dietary Guidelines. At present, solid fats and added sugars represent approximately 35 percent of calories consumed by Americans—children, adolescents, adults, and older adults, and both males and females—and contribute significantly to excess calorie intake without contributing significantly to overall nutrient adequacy. In an eating pattern within calorie limits, calories from solid fats and added sugars are more likely to contribute to weight gain than calories from other food sources. Furthermore, as solid fats and added sugars increase in the diet, it becomes difficult for individuals to meet nutrient needs while staying within calorie limits. Most Americans can accommodate only 5-15 percent of calories from solid fats and added sugars in an eating pattern that meets nutrient needs within calorie limits (USDA/HHS, 2010). The amount of calories consumed should vary based on a person’s age, sex, and physical activity level (see Chapter 5 for recommendations related to physi- cal activity). Table 6-1 summarizes estimated daily calorie needs by age, sex, and activity level. Most Americans consume too many calories on a daily basis given their age, sex, and activity level, and the calories they consume are often high in added sugars and solid fats rather than the items recommended by the Dietary Guidelines (Figure 6-1). RECOMMENDATION 2 Governments and decision makers in the business community/private sector6 should make a concerted effort to reduce unhealthy food and beverage options7 and substantially increase healthier food and beverage options at affordable, competitive prices. Food and beverage environments are one of the five critical areas for accel- erating progress in obesity prevention identified by the committee (Figure 6-2).12 Increasing access to healthy food and beverage options and decreasing consump- tion of solid fats and added sugars are important steps toward achieving energy 6 The business community/private sector includes private employers and 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. 7 Although there is no consensus on the definition of “unhealthy” foods/beverages, the term refers in this report to foods and beverages that are calorie-dense and low in naturally occurring nutrients. Such foods and beverages contribute little fiber and few essential nutrients and phytochemicals, but contain added fats, sweeteners, sodium, and other ingredients. Unhealthy foods and beverages displace the consumption of foods recommended in the Dietary Guidelines for Americans and may lead to the development of obesity. Accelerating Progress in Obesity Prevention 162

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TABLE 6-1 Estimated Calorie Needs per Day by Age, Sex, and Physical Activity Levela Physical Activity Levelb Sex Age (years) Sedentary Moderately Active Active 1,000-1,200c 1,000-1,400c 1,000-1,400c Child (female and male) 2-3 Femaled 4-8 1,200-1,400 1,400-1,600 1,400-1,800 9-13 1,400-1,600 1,600-2,000 1,800-2,200 14-18 1,800 2,000 2,400 19-30 1,800-2,000 2,000-2,200 2,400 31-50 1,800 2,000 2,200 51+ 1,600 1,800 2,000-2,200 Male 4-8 1,200-1,400 1,400-1,600 1,600-2,000 9-13 1,600-2,000 1,800-2,200 2,000-2,600 14-18 2,000-2,400 2,400-2,800 2,800-3,200 19-30 2,400-2,600 2,600-2,800 3,000 31-50 2,200-2,400 2,400-2,600 2,800-3,000 51+ 2,000-2,200 2,200-2,400 2,400-2,800 NOTE: Estimates are rounded to the nearest 200 calories. An individual’s calorie needs may be higher or lower than these average estimates. aBased on estimated energy requirement (EER) equations, using reference heights (average) and reference weights (healthy) for each age/gender group. For children and adolescents, reference height and weight vary. For adults, the reference man is 5 feet, 10 inches tall and weighs 154 pounds. The reference woman is 5 feet, 4 inches tall and weighs 126 pounds. EER equations are from IOM (2002). bSedentary means a lifestyle that includes only the light physical activity associated with typical day-to-day life. Moderately active means a lifestyle that includes physical activity equivalent to walking about 1.5 to 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life. Active means a lifestyle that includes physical activity equivalent to walking more than 3 miles per day at 3 to 4 miles per hour, in addition to the light physical activity associated with typical day-to-day life. cThe calorie ranges shown are to accommodate needs of different ages within the group. For children and adolescents, more calories are needed at older ages. For adults, fewer calories are needed at older ages. dEstimates for females do not include women who are pregnant or breastfeeding. SOURCE: HHS/USDA, 2010. 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 agri- culture policies; population growth; and economic, social, and lifestyle changes (Story et al., 2008). Food now is readily available and accessible in many set- tings throughout the day. The current U.S. food supply contains a large amount 163 Food and Beverage Environments

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