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Introduction and Workshop Overview

On June 21–22, 2017, the Food and Nutrition Board of the National Academies of Sciences, Engineering, and Medicine convened A Workshop on Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Evaluation of Federal, State, and Local Policies and Programs,^1,2 in Washington, DC. As guided by the Statement of Task (see Box 1-1), the workshop had five objectives:

1. Provide an overview of current and emerging strategies to reduce consumption of sugar-sweetened beverages by young children 0 to 5 years of age and explore the evidence on effectiveness;
2. Contextualize the strategies by broadly considering patterns and trends in beverage consumption, and specifically sugar-sweetened beverage consumption, in U.S. children;

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¹ The planning committee’s role was limited to planning the workshop, and this Proceedings of a Workshop was prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

² For consistency of language, the term sugar-sweetened beverages will be used throughout this Proceedings of a Workshop in lieu of other terms and abbreviations used by the speakers and moderators (e.g., sugary drinks, SSBs). A definition of sugar-sweetened beverages was not established for this workshop. Instead, speakers were asked to include in their presentations an explanation of the beverages to which they were referring when using the phrase. Unless otherwise noted, speakers discussed 100 percent fruit juice as a category separate from sugar-sweetened beverages.

3. Examine current guidelines for beverage intake applicable to children 5 years of age and younger;
4. Explore the role of industry in sugar-sweetened beverage intake in young children; and
5. Identify where knowledge gaps and opportunities exist to inform future policies, programs, and strategies.

This Proceedings of a Workshop summarizes the presentations and discussions that took place over the course of the workshop.³ This proceedings also expands on the key points highlighted in the Proceedings of a Workshop—in Brief (NASEM, 2017). It is not intended to be a comprehensive summary of the topic. Furthermore, citations herein correspond to those presented on speaker’s slides and explicitly referred to during discussions, and do not constitute a comprehensive reference list on any of the subjects covered during the workshop. A bibliography of references used to inform workshop planning, provided as a handout at the workshop, is presented in Appendix C.

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³ Materials from the workshop, including presentations and videos, can be found at http://nationalacademies.org/hmd/Activities/Nutrition/StrategiesToLimitSSBConsumptioninYoungChildren/2017-JUN-21.aspx (accessed November 13, 2017).

ORGANIZATION OF THIS PROCEEDINGS OF A WORKSHOP

The organization of this Proceedings of a Workshop parallels the workshop agenda. This chapter provides an overview of the objectives and scope of the workshop, along with welcoming and opening remarks. Chapter 2 summarizes Session 1 presentations and discussions. Speakers provided context for the policies and programs by presenting prevalence and trends in beverage intake, discussing the potential cost-effectiveness of different strategies, and describing considerations related to drinking water. Chapter 3 summarizes Session 2 presentations on the scientific report of the 2015 Dietary Guidelines Advisory Committee and the guidelines from the American Academy of Pediatrics. Chapter 4 summarizes Session 3, in which speakers discussed a wide range of strategies that have been implemented at different levels throughout the United States. Chapter 5 summarizes Session 4 presentations, which explored programs and policies that could potentially be scaled up. Chapter 6 summarizes Session 5, in which presenters considered how industry has contributed to current consumption patterns and approaches industry is taking to reduce sugar-sweetened beverage consumption in young children. Chapter 7 captures an invited reflection on the workshop in Session 6, along with a panel discussion on evidence gaps and research needs that exist and possible opportunities to fill such gaps. References cited throughout this proceedings follow Chapter 7. The workshop agenda is presented in Appendix A. Biographical sketches of the speakers and session moderators are presented in Appendix B. A bibliography of references used to inform workshop planning is presented in Appendix C.

WELCOMING REMARKS

To open the workshop, Karen Weber Cullen, professor of pediatrics-nutrition with Children’s Nutrition Research Center at the Baylor College of Medicine and chair of the planning committee, explained that the workshop agenda was developed by considering a day in the life of a young child. She noted that there are various settings in which someone makes a decision to offer a child a beverage and that a number of influences have the potential to affect the decision for the child to be served or to consume a sugar-sweetened beverage.

Discussing the format of the workshop, Cullen briefly explained the facilitated discussion format. Audience members were asked to record their questions for speakers on index cards or submit their questions via the webcast platform. Moderators were to use the audience questions to guide the discussion portion of the session.

OPENING REMARKS FROM THE WORKSHOP SPONSORS

After Cullen’s welcome, a speaker from each of the three workshop sponsors provided brief opening remarks, describing the interest of their respective organizations in exploring the current landscape of national, state, tribal, and local strategies to limit sugar-sweetened beverage consumption in young children.

Tina Kauh, Research-Evaluation-Learning senior program officer at the Robert Wood Johnson Foundation (RWJF), began by explaining that her organization “has a vision for a nation that lives by a culture of health in which everyone in a diverse society has the opportunity to lead healthy lives, now and for generations to come.” Healthy Children, Healthy Weight—one component of RWJF’s approach to achieving its vision—is guided by the recognition that children need environments that foster health and that families should have the chance to provide such an environment to their children. Kauh explained that many children in the United States do not have the necessities needed to support their physical, social, and emotional development, which she noted are elements of health that begin developing early in life. Accordingly, RWJF considers health promotion in early childhood and health equity to be major priorities. Kauh explained how limiting sugar-sweetened beverage consumption among young children aligns with these priorities. She noted that by 2 years of age, approximately one in three children consumes sugar-sweetened beverages on a given day, and that sugar-sweetened beverages contribute approximately 100 calories per day to the diets of children 2 to 5 years of age. Disparities in intake also exist, such as greater sugar-sweetened beverage consumption among black children and children from families with lower socioeconomic status. Kauh stated that RWJF views safe drinking water as the healthiest beverage option for young children and suggested that increasing drinking water intake could be one mechanism for decreasing sugar-sweetened beverage intake. Recognizing that young children interact with a variety of caregivers—parents, teachers, child care providers—Kauh explained that RWJF will be working over the next several years to identify and support policy opportunities that can potentially improve the health and well-being of young children in settings where they spend much of their time.

Judi Larsen, program manager for The California Endowment, provided a brief overview of her organization. With priorities that include prevention and racial equity, The California Endowment works with a variety of leaders throughout the state of California to support building healthier communities. Larsen explained that The California Endowment’s work seeks to operate through collective, rather than individual, action. As such, support is given to grassroots organizations and leaders. The California Endowment has worked in the area of limiting sugar-sweetened beverage

consumption for 20 years, and has been “deliberate and intentional about making sure that water is readily available and free.” Larsen noted that her organization’s efforts on this topic have included evaluating the retail environment, developing strong messaging and communications, and working in a collective manner. Based on its experience, which included supporting the 1995 efforts to fluoridate the public water systems in California, The California Endowment recognizes the importance of understanding the community context. “We feel really strongly that a more explicit focus on racial equity creates more local ownership,” said Larsen, noting that change in policies and practices can arise from pressure from the local community and local leadership. Larsen concluded her remarks by suggesting that there are opportunities to better align initiatives to improve drinking water access and efforts to limit sugar-sweetened beverage consumption.

Robert Post, senior director at the Chobani Nutrition Center and advisor to the Chobani Foundation, explained that the Chobani Foundation supports efforts that improve access to healthier food options, empower better food choices, and promote health, wellness, sports, and fitness in communities in Idaho, New York, and throughout the United States. From such work, the Chobani Foundation has come to recognize that families, seeking to make the best choices for their children’s health, “want to know all the options for replacing empty calories [sugar-sweetened beverages] provide, and that means nutrient-dense beverages and foods and water,” said Post. He stated that “there are many pieces of the puzzle to assess policies and programs to limit [sugar-sweetened beverages].” The Chobani Foundation’s experience has revealed the importance of pragmatic and actionable policies and programs. Recognizing that the context of the entire diet needs to be considered, Post presented evidence from the 2015–2020 Dietary Guidelines for Americans (HHS/USDA, 2015a) showing that children are consuming too many added sugars and too few nutrient-dense foods. Post wondered if programs and policies are leading to displacement of nutrient-deficient calories with nutrient-dense calories and whether they are incentivizing innovation and renovation to create more nutrient-dense beverages in the food sector to meet needs. He offered that dietary shifts require individuals to replace less healthy choices, which requires a “how to” approach showing simple shifts that can improve dietary quality and may be able to “stick” over the long run without banning or excluding certain foods. Citing Zheng et al. (2015), Post noted that displacing sugar-sweetened beverages with milk and water in children’s diets is inversely associated with the development of obesity. As such, he suggested that dietary shifts from options of low-nutrient density to high-nutrient density are needed to improve dietary intake quality.

Post underscored the need for policies and programs that have evidence of working in real-world settings. He presented evidence for nutrition

education approaches, policy systems, and environmental approaches that emphasize the concept of nutrient-density to fill the gap created in reducing sugar-sweetened beverage consumption (Anzman-Frasca et al., 2015; Bender et al., 2013; Goldberg et al., 2015; Kenney et al., 2015a; Raynor et al., 2012; Silver et al., 2017; Wang et al., 2012; Wright et al., 2015). Post pointed to evidence that sugar-sweetened beverage consumption is associated with poor diet quality and other adverse health behaviors (Arsenault et al., 2017; Burgermaster et al., 2017; Piernas et al., 2015) and noted that food pattern modeling can be used to assess dietary effects of meeting recommended intake levels (Britten et al., 2012). He concluded that in order to understand the effects of reducing, limiting, or replacing sugar-sweetened beverages from children’s diets, each of which has unique nutritional effects, behavior in the context of the whole dietary pattern has to be considered.