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Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
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2

Setting the Stage

To begin the first session, moderator Leann Birch, William P. Flatt Professor at the University of Georgia, noted that the human diet begins as a single drink—milk—and progressively becomes more varied, a transition that is relatively complete by the time a child reaches 2 years of age. It is during this transformational period that infants and young children learn how and what to eat. What is learned stems from the home setting and the family environment, and depends on a variety of factors, including “culture, ethnicity, socioeconomic status, feeding practices, and what foods happen to be available,” said Birch. “We learn to associate foods with particular contexts, consequences, and with other flavors, and we watch others eat and we learn that way as well,” she added. Repeated exposure to foods, drinks, and flavors is generally needed for an infant to gain familiarity and develop preferences. The liking for the taste of sweet, however, is unique. As an unlearned response, Birch continued, the preference for sweet serves as “an unconditioned stimulus for ingestion” that leads to an endogenous opioid release and can have an analgesic effect.

Drawing on points made in a commentary by Giddings and Mennella (2016), Birch indicated that the widespread availability of sweet in the food supply, coupled with the innate preference for the taste, has made young children susceptible to displacing other foods in the diet with items that are sweet. Putting her remarks in context of the workshop, Birch stated “This is what [we are] up against if you want [children] to drink water instead of sugar-sweetened beverages.”

To provide a foundation for the strategies, policies, and programs discussed throughout the workshop, the session continued with presentations

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

from four speakers. Anna Maria Siega-Riz, professor at the University of Virginia, and Mary Story, professor at Duke University, each discussed prevalence and trends in beverage intake among young children and highlighted disparities in sugar-sweetened beverage intake. Steven Gortmaker, professor of the practice of health sociology at the Harvard T.H. Chan School of Public Health, then described the estimated cost-effectiveness and projected health effect of three strategies to limit sugar-sweetened beverage intake in young children. Finally, Christina Hecht, senior policy advisor at the University of California Nutrition Policy Institute, provided an overview of considerations related to the safety, access, and promotion of drinking water. A facilitated discussion with all four session speakers followed the presentations.

PREVALENCE, TRENDS, AND DISPARITIES IN BEVERAGE INTAKE AMONG YOUNG CHILDREN

To provide insight into the current beverage intake levels, patterns, trends, and population group differences, Siega-Riz first presented evidence from two recent publications that used 2005–2012 National Health and Nutrition Examination Survey (NHANES) data on the beverage consumption of children from 0 to 23.9 months of age (Grimes et al., 2015; Miles and Siega-Riz, 2017). Story then discussed similar analyses of data of children 0 to 47.9 months of age from the Feeding Infants and Toddlers Study (FITS) 2016.

Findings from NHANES for Children 0 to 23.9 Months of Age1

Infant formula, human milk, and infant foods are the primary foods consumed by infants from 0 to 5.9 months of age, providing 99.3 percent of daily total energy intake (Grimes et al., 2015). The food sources contributing to total energy intake are more varied for infants 6 to 11.9 months of age. Siega-Riz noted that one of the first sweet beverages introduced to young children is 100 percent fruit juice. She explained that 6 percent of infants 0 to 5.9 months of age consume 100 percent fruit juice, a proportion that increases to approximately 38 percent among infants 6 to 11.9 months of age and 57 percent among children 12 to 23.9 months of age (Grimes et al., 2015). In addition to consumption becoming more prevalent, 100 percent fruit juice also contributes to a greater proportion of total energy intake with increasing age. One hundred percent fruit juice accounts for approximately 1.5 percent of total energy intake among infants 6 to 11.9 months of age and 5.9 percent among children 12 to 23.9 months of age

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1 This section summarizes information presented by Anna Maria Siega-Riz.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

(Grimes et al., 2015). Furthermore, 100 percent juice is the fifth largest contributor to intake of total sugars among infants 6 to 11.9 months of age and the second largest contributor to intake of total sugars among children 12 to 23.9 months of age. Compared to 2005–2008, the overall prevalence of 100 percent fruit juice intake in 2009–2012 decreased among infants 0 to 5.9 and 6 to 11.9 months of age (Miles and Siega-Riz, 2017).

For context, Siega-Riz showed that prevalence of breastmilk, formula, and cow’s milk intake among children 0 to 23.9 months of age remained relatively stable between 2005–2008 and 2009–2012 (Miles and Siega-Riz, 2017).

Siega-Riz then discussed sugar-sweetened beverages, which she defined as “carbonated soda, fruit-flavored drinks, sports drinks, [and] presweetened tea or other beverages.” Approximately 1 percent of infants 0 to 5.9 months of age consume such beverages, with the proportion increasing to approximately 6 percent among infants 6 to 11.9 months of age and 32 percent among children 12 to 23.9 months of age (Grimes et al., 2015). Among children 12 to 23.9 months of age, sugar-sweetened beverages contribute 3.1 percent of total energy intake (Grimes et al., 2015). Siega-Riz acknowledged that the contribution of sugar-sweetened beverages to intake of total sugars among infants 6 to 11.9 months of age is small, but such beverages are the fourth largest contributor to intake of total sugars among children 12 to 23.9 months of age. Although there was no change in the overall prevalence in sugar-sweetened beverage consumption among children 6 to 23.9 months of age between 2005–2008 and 2009–2012, the prevalence of intake among Mexican-American children appears to be decreasing, largely attributed to reductions in soda intake (Miles and Siega-Riz, 2017). Fruit-flavored drink consumption did not significantly change in the overall sample or for any of the evaluated population groups between 2005–2008 and 2009–2012. Siega-Riz noted, however, that more non-Hispanic black children and Mexican-American children 6 to 23.9 months of age consume fruit-flavored drinks as compared to their non-Hispanic white counterparts.

Findings from FITS for Children 0 to 47.9 Months of Age2

FITS 2016 is a national, cross-sectional survey of parents and caregivers of U.S. infants, toddlers, and preschool-age children sponsored and funded by Nestlé Research and designed and carried out by RTI International, explained Story. Conducted in 2002, 2008, and 2016, FITS aims to collect data on infant feeding practices, nutrient intakes, food intakes, dietary patterns, and lifestyle behaviors. Dietary intake data are collected via a 24-

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2 This section summarizes information presented by Mary Story.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

hour recall, with a subsample of participants providing two 24-hour recalls. The overall sample for FITS 2016, which consisted of 3,234 households with at least one child younger than 48 months, “reflects the geographic and sociodemographic diversity of the [United States],” described Story.

Analyses of FITS 2016 data indicate that a dietary shift occurs around 12 months of age, and, during this time, sweets and snacks begin to play an increasing role in the diet. Sweets and snacks contribute 9 percent of total energy intake among children 12 to 14.9 months of age, a proportion that progressively increases to 19 percent of total energy intake among children 36 to 47.9 months of age. Expressed as energy per capita, children 36 to 47.9 months of age consume approximately 224 calories from sweets per day. Story noted that 100 percent juice does not follow the same trend across age groups, as it contributes a relatively consistent 4 to 5 percent of total energy intake among older infants, toddlers, and preschool-age children.

After providing the context of total dietary intake of children 0 to 47.9 months of age, Story presented analyses specifically exploring beverage intake. She showed that water and milk are the most commonly consumed beverages among young children in this age range. Story highlighted two issues concerning milk intake. First, evidence from FITS 2016 suggests that there are infants being introduced to cow’s milk before the recommended age of 12 months. Furthermore, approximately 15 to 20 percent of children 12 months of age and older did not consume any milk on the day of the survey, which Story indicated has implications for diet quality.

Story defined the category of sugar-sweetened beverages as “soft drinks, fruit-flavored drinks, teas and coffee, sports drinks, and other drinks, such as caloric flavored water or energy drinks.” She noted the definition did not include flavored milk and 100 percent fruit juice. Evidence from FITS 2016 shows the proportion of children consuming sugar-sweetened beverages increased with increasing age. Approximately 1 percent of children 0 to 5.9 months of age reportedly consumed any sugar-sweetened beverages on the day of the survey. This proportion increased to 50 percent among children 36 to 47.9 months of age, making sugar-sweetened beverage intake more prevalent than 100 percent fruit juice intake in this age group. Children 12 months of age and older who reportedly consumed sugar-sweetened beverages on the day of the survey, consumed approximately 100–110 calories from such products, said Story. Sugar-sweetened beverages contribute to 5 percent of total calories per capita among children 12 to 17.9 months of age, a proportion that increases to 10 percent among children 36 to 47.9 months of age. Among the different types of sugar-sweetened beverages, fruit-flavored drinks are the most commonly consumed type and contribute to the majority of sugar-sweetened beverage calories consumed among children 0 to 47.9 months of age.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

Story touched on trends in beverage intake across FITS 2002, 2008, and 2016 data. Drawing a parallel with the evidence presented by Siega-Riz, Story showed that the prevalence of 100 percent fruit juice intake has decreased over time in all evaluated age groups. In contrast, the trends in the prevalence in sugar-sweetened beverage intake over time are mixed across the evaluated age groups. Some age groups appear to have decreased intake over time (e.g., children 21 to 24 month of age), while other age groups appear to have slightly increased intake (e.g., children 9 to 12 months of age).

Differences emerged when sugar-sweetened beverage intake was evaluated by race and ethnic groups. Intake was more common and, among consumers, contributed more calories per day among non-Hispanic black children 24 to 47.9 months of age than among non-Hispanic white and Hispanic children in the same age range. Story explained that these differences were primarily driven by more widespread fruit-flavored drink intake among non-Hispanic black children.

At the end her presentation, Story described potential future analyses of the FITS 2016 data and discussed what she perceived as evidence gaps. She suggested that opportunities exist to use FITS 2016 to explore beverage intake patterns by meal and snack occasion, by location (including different child care settings as compared to the home setting), and by income level. Speaking more broadly, Story thought that opportunities exist to better understand parent and caregiver attitudes and beliefs regarding beverages in the diets of young children, especially health beliefs about fruit-flavored drinks. Story also believes a need exists to better understand sugar-sweetened beverage intake in the context of overall dietary intake and diet quality, including as it relates to total energy intake and consumption of fruits, vegetables, and whole grains. She concluded her presentation by proposing that more data are needed on young children 48 months of age and older.

COST-EFFECTIVE STRATEGIES TO LIMIT SUGAR-SWEETENED BEVERAGES IN CHILDREN: WHAT CAN WE EXPECT?3

In his presentation, Gortmaker described select findings from the Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) (President and Fellows of Harvard College, 2015). CHOICES is a project that aims to estimate the cost-effectiveness and population health effect of obesity prevention programs and policies. Gortmaker’s team has assessed nearly 50 obesity strategies and has searched for evidence of effect by performing systematic reviews on more than 130,000 peer-reviewed articles. Drawing

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3 This section summarizes information presented by Steven Gortmaker.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
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FIGURE 2-1 Approach to creating microsimulation models for dietary intake and physical activity intervention scenarios as part of the Childhood Obesity Intervention Cost Effectiveness Study (CHOICES).
NOTE: BMI = body mass index; BRFSS = Behavioral Risk Factor Surveillance System; NHANES = National Health and Nutrition Examination Study.
SOURCE: As presented by Steven Gortmaker, June 21, 2017.

on big data at the national, state, and local levels, Gortmaker’s team has created microsimulation models to estimate the cost-effectiveness of an intervention over a 10-year period and to project how it would affect health outcomes such as obesity and mortality (Cradock et al., 2017; Dietz and Gortmaker, 2016; Gortmaker et al., 2015) (see Figure 2-1). The models require “estimates of reach, estimates of effect, and cost,” he noted.

Through CHOICES, Gortmaker’s team has evaluated strategies directly related to sugar-sweetened beverages, a category of beverages he defined as including “soda, sports drinks, fruit drinks and punches, [and] sweetened tea,” but not including flavored milk or 100 percent fruit juice. Citing evidence from Wang et al. (2008), which showed that children 2 to 5 years of age consume the majority of calories from sugar-sweetened beverages at home, Gortmaker suggested that interventions likely to have the greatest effect on the intake among young children are those that affect the home setting.

The evidence to support the effect of changing sugar-sweetened beverage intake on body mass index and obesity in children is “quite strong,”

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

noted Gortmaker. An 18-month double-blind, randomized trial of sugar-free and sugar-sweetened beverages in Dutch children 4 to 11 years of age provides evidence that sugar-sweetened beverage intake affects relative weight (de Ruyter et al., 2012). Another analysis of the Dutch study data found that children with higher body mass indexes may not compensate as much as leaner children when the sugar-sweetened beverages are replaced with sugar-free beverages (Katan et al., 2016). In considering the applicability to U.S. children, Gortmaker observed that the higher body mass index group in the Dutch analyses was comparable to the average body mass index among children 6 to 11 years of age in the United States (Ogden et al., 2012). Accordingly, he thought the effect on body weight status may be underestimated for U.S. children. Evidence of the effect of changing sugar-sweetened beverage intake on body weight status in young children birth to 5 years of age is less robust. Gortmaker explained that fewer studies are conducted in this age range and that collecting accurate dietary intake data on young children is an issue because it is “pretty hard to know how much went in their mouth, how much went on the floor, [and] what did they really consume.” Nevertheless, he suggested that the relationship documented in other age groups is likely to exist in younger children.

After providing the context of evidence of effect, Gortmaker described the published results from his group’s microsimulation models for three interventions: sugar-sweetened beverage excise tax, Smart Snacks in Schools, and the Nutrition and Physical Activity Self-Assessment for Child Care (NAP SACC) (Gortmaker et al., 2015). Owing to differences in scale and expected reach, the interventions had various projected outcomes of cases of obesity prevented over a 10-year period and cost-effectiveness. Speaking broadly about the interventions his group has modeled, Gortmaker remarked that few result in cost savings.

The models indicate that a one-cent-per-ounce excise tax on sugar-sweetened beverages, if implemented across the United States, would have the greatest effect of the three interventions. The excise tax is projected to prevent nearly 580,000 cases of childhood obesity and to provide more than $30 in health care cost savings for every $1 invested, noted Gortmaker. He further explained that an increase in the price of sugar-sweetened beverages would lead to lower consumption, especially among population groups that have higher intake. As such, the sugar-sweetened beverage excise tax has the potential to reduce racial/ethnic and socioeconomic disparities in intake (Long et al., 2016). It could further improve health equity, observed Gortmaker, if the estimated $12.5 billion in revenue generated per year from the tax were to be invested in other preventative activities. He acknowledged that limited work is currently being done to evaluate the effect of existing sugar-sweetened beverage taxes on children, and he identified this as a research opportunity.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

Smart Snacks in Schools is expected to have similar effects as the sugar-sweetened beverage excise tax, but to a lesser degree. The microsimulation model estimated that Smart Snacks in Schools would prevent approximately 345,000 cases of childhood obesity, and would result in a nearly $5 health care cost savings for every $1 invested, Gortmaker said.

NAP SACC is an intervention used to change the nutrition profile of food provided in the early care and educational setting. Gortmaker reported that because it would have a smaller reach than the sugar-sweetened excise tax and the Smart Snacks in Schools initiative, NAP SACC is projected to prevent far fewer cases of childhood obesity—approximately 38,000 cases. In contrast to the two other interventions, NAP SACC would not result in health care cost savings, but instead would only return $0.04 to $0.08 for every $1 invested, he continued. The NAP SACC microsimulation model offered additional findings of interest. Although it is likely to not have a large effect on obesity, the models indicated that replacing 100 percent fruit juice with water in a typical child care center with 30 children could save approximately $1,000 per year at that center, noted Gortmaker. He emphasized that sugar-sweetened beverage habits and practices start early in life, and that opportunities exist to make early care and educational settings healthier.

Gortmaker pointed out that when modeling the effects of interventions limiting 100 percent fruit juice consumption, changes in intake lead to changes in weight in adults (Mozaffarian et al., 2011). He explained that it is difficult to detect such a relationship in children because of the limitations of current data and because there are few longitudinal studies of young children. Emphasizing a point he made earlier in his presentation, Gortmaker thought that unreliable dietary intake data is one reason the relationship between change in 100 percent fruit juice intake and change in weight in children has been inconsistent in the literature. In presenting results from Ludwig et al. (2001), Gortmaker underscored the importance of analyses evaluating change in sugar-sweetened beverage intake with change in body mass index, rather than looking at baseline intake alone.

DRINKING WATER: WHAT DO WE NEED TO KNOW AND DO?4

Although limited in nature, evidence suggests that infants and toddlers are adequately hydrated, but are likely to be under-hydrated by the time they reach school age (Drewnowski et al., 2013; Grimes et al., 2017; Kant et al., 2010; Kenney et al., 2015b). Presenting evidence from recent NHANES analyses, Hecht noted that the majority of, but not all, children 6 months through 5 years of age reportedly consume water (Grimes et al.,

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4 This section summarizes information presented by Christina Hecht.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

2017; Watowicz et al., 2015). Further emphasizing this point, she reported that an analysis using 2005–2010 NHANES data found that 83 percent of children 1 to 19 years of age consumed tap water, 10 percent consumed bottled water, and 7 percent reportedly consumed no water (Patel et al., 2013). Tap water consumption was less common among female, Hispanic, and black children and was twice as common among children with a college-educated parent (Patel et al., 2013). Hecht described tap water as economical, “a disparity reducer,” and, when fluoridated, a contributor to oral health. Given that unhealthy beverage intake patterns start developing in early childhood, “We want to make plain water the normative beverage after age-appropriate amounts of milk in this age group,” said Hecht. To establish water intake as a habit in young children, Hecht highlighted the importance of safety, access, and promotion.

Water Safety

Infant formula, which is typically prepared using tap water, is consumed by the majority of infants in the United States (Grimes et al., 2017; Miles and Siega-Riz, 2017). Hecht noted that 60 percent of infants 0 to 5 months of age are exclusively formula fed. The risk of exposure to lead in tap water is a concern in formula-fed infants because they can consume upwards of 4 cups of infant formula per day, which is more water in proportion to body weight than any other age group. Lead is particularly toxic to children younger than 7 years of age because they have greater gastrointestinal absorption and are more vulnerable to the neurotoxic effects, stated Hecht. She noted that other factors associated with formula feeding, such as socioeconomic status and zip code, also appear to be associated with an elevated risk of unsafe tap water (Edwards et al., 2009).

Hecht explained that there are two categories of water contamination. One category is contaminated source water that is not properly treated by the water utility. Approximately 5 percent of water utilities provide contaminated water to their customers, she noted. The other source of water contamination occurs after leaving the main line of the water utility. When service lines are made of lead or when lead is present in premise plumbing, lead can either leach or flake into the water and contaminate it (Triantafyllidou and Edwards, 2012).

Despite a lack of surveillance data, evidence drawn from media reports indicates that tap water contamination occurs throughout the United States (see Figure 2-2), suggesting that “existing regulations, guidelines, and systems do not always safeguard our water,” said Hecht. She explained that there are locations particularly susceptible to unsafe water, including “areas subject to agricultural runoff, industrial pollution, mining or fracking activities, and rural and inner-city areas.” Hecht reported that, to date,

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
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FIGURE 2-2 Media reports of tap water contamination since January 2015.
SOURCES: As presented by Christina Hecht, June 21, 2017. Copyright © 2017 The Regents of the University of California. Used by permission.

only 14 states and the District of Columbia have mandatory or voluntary testing of lead in school tap water, and each varies in its approach to testing. In New York State, which has mandatory testing, nearly 12 percent of taps had lead levels exceeding 15 parts per billion,5 the action level set by the U.S. Environmental Protection Agency. Even fewer states have provisions regarding testing tap water in child care settings. Hecht recounted a conversation she had with a coordinator of the Rhode Island Department of Health program offering voluntary testing in Rhode Island child care centers. The coordinator indicated that participation in the program had been low because the child care centers feared the cost of remedying any issue found. As another example, Hecht noted that mandatory testing in the state of Washington is contingent on appropriated funding and, at the time of the workshop, funding had yet to be allocated.

Water Access and Consumption

When improved access to water is paired with education, water consumption is increased, explained Hecht, who used two studies to exemplify her point. A trial in German elementary schools by Muckelbauer et al. (2009) showed that increased access to water fountains and reusable

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5 Later in her presentation Hecht noted that the American Academy of Pediatrics recommends that school water fountains should have water lead concentrations that do not exceed one part per billion (Council on Environmental Health, 2016).

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

bottles, coupled with teacher-led education on water, increased students’ daily water intake by 220 milliliters and reduced the risk of overweight in the intervention schools as compared to the control schools. Kenney et al. (2015a) reported that providing access to cups during school lunch and promoting water through posters increased the number of students who consumed water, increased the amount of water students consumed, and appeared to reduce the number of students who consumed sugar-sweetened beverages. Similar trials in the child care setting are lacking, observed Hecht.

Hecht stated, “Policy on water can be a key lever for access,” noting that such policies exist in the federal child nutrition programs. Effective October 1, 2017, providers participating in the Child and Adult Care Food Program (CACFP) are required to make water available as well as to offer water with visual cues over the course of the day. Hecht highlighted that the new CACFP standards are well-aligned with recent recommendations made by the American Academy of Pediatrics and by an expert panel convened by the Robert Wood Johnson Foundation Healthy Eating Research program. She also noted that the update in policy affects not only CACFP providers (which includes one-half of all licensed child care providers), but also the licensed child care providers in the one-half of U.S. states that link licensure nutrition standards to CACFP regulations.

Water Promotion

Hecht emphasized the importance of drinking water promotion and education, together with improving access, as a key facilitator in boosting water consumption in preference to sugar-sweetened beverages, and she showed a variety of promotional materials aimed at the early years. Hecht concluded by outlining barriers to and opportunities for the role of drinking water access and promotion in an effort to eliminate sugar-sweetened beverage consumption in children 0 to 5 years of age. She suggested that barriers include gaps in the evidence base including the lack of definitive evidence that increased water consumption does not displace other healthy beverages and foods in the diet, although preliminary findings suggest it does not (Ritchie et al., 2012).

Hecht believes that misperceptions about water safety are a more substantial barrier than actual safety, but she noted that evidence gaps about safety do exist. She also emphasized the importance of modeling behaviors and that many parents and caregivers drink sugar-sweetened beverages themselves. Hecht recognized that parents and caregivers also receive a range of mixed messages regarding healthy beverages. To rectify this, she thought an opportunity exists to improve clarity for parents and caretakers on what beverages children should be drinking, how the beverages should

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

be offered, and how much of the beverage should be provided. She also suggested that education is a necessary component of water promotion and could be enhanced by including strong language in the 2020–2025 Dietary Guidelines for Americans and adding a symbol for water on the MyPlate graphic.

FACILITATED DISCUSSION WITH THE AUDIENCE

Following the presentations, Birch moderated a facilitated discussion between the audience and Siega-Riz, Story, Gortmaker, and Hecht. The sections below summarize topics that emerged during the conversation.

Data Quality and Evidence Gaps

Birch opened the facilitated discussion by asking the session speakers what data would be ideal to fill existing gaps. Story thought that there should be greater investment in improving dietary assessment methods. She acknowledged that groups are currently working on this issue, innovating through use of smartphones and use of pictures. Building on this point, Gortmaker noted that an opportunity exists, such as using phones to take pictures or videos, to “gather more precise estimates to validate all the recall methods.” Bringing the conversation specifically back to beverages, Story believed that people were more aware of what kind and what size beverage they consume than how much they eat. Hecht wondered if packaged beverages were more readily recalled than tap water. Related to this topic, Hecht reiterated a point made during her presentation: more data on tap water quality is needed.

Noting that she was less concerned with the precision of dietary intake data than with the overall trend, Siega-Riz explained that understanding how beverage consumption tracks with weight in children is challenging, because data are largely cross-sectional. She identified the lack of longitudinal data on U.S. children from birth as a major gap in existing evidence. Siega-Riz further explained that sample sizes in NHANES for young children are relatively small, limiting the number and types of additional analyses or subgroup comparisons that can be performed. When an audience member proposed looking at sugar-sweetened beverage consumption by acculturation status, Siega-Riz noted that the NHANES sample would be too small, especially if also broken down by age group.

Testing of Drinking Water

Drawing from an audience member-submitted question, Birch asked Hecht to describe what has facilitated the passing of regulations for testing

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

tap water in schools and child care facilities. Although she admitted to not knowing the background of what happened in every state, Hecht explained that in California “it was thanks to the work of a very strong network of drinking water advocates who work on all sorts of drinking water issues.” Siega-Riz emphasized that the map that Hecht showed during her presentation (see Figure 2-2) was based on media reports, and as such most likely reflected a sizeable underestimation of contamination in the United States. Drawing attention to this, she suggested that mandatory testing would be needed to truly understand the scope of water safety issues nationwide.

Gortmaker remarked that funds are generally allocated for testing rather than remedying any issues found, although Hecht noted that the initiative in California has money for both testing and remediation. Siega-Riz proposed that some of the funds from the excise tax on sugar-sweetened beverages could be put toward resolving water contamination issues found through testing, creating what she perceived as “a win-win solution.” Hecht agreed with Siega-Riz, but thought this approach could create equity issues, given where the sugar-sweetened beverage excise taxes have been approved at the city level.

100 Percent Fruit Juice

Birch posed a series of audience questions regarding 100 percent fruit juice. An audience member wanted to know about the dietary effects of 100 percent juice consumption. Siega-Riz explained that although 100 percent fruit juice does provide vitamin C, it does not provide fiber and some of the nutrients that are found in whole fruit. When asked if 100 percent juice leads to greater sugar-sweetened beverage intake, Siega-Riz repeated a finding from her presentation—100 percent fruit juice is one of the first complementary foods introduced to infants. Gortmaker added that the longitudinal study of Sonneville et al. (2015) found that early juice consumption predicts later sugar-sweetened beverage consumption.

Location of Exposure

An audience member wanted to know if non-Hispanic black children are being exposed to sugar-sweetened beverages at home or in the child care setting, a question Birch believed was related to the data presented earlier in the session indicating that this population group had greater sugar-sweetened beverage intake. Gortmaker replied that in low-income populations, sugar-sweetened beverages are more likely to be found in family-based child care settings rather than child care centers. Siega-Riz hypothesized that the differences emerging in the Hispanic population may be attributed, in part, to the changes in the food packages offered by the

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) that took effect during the period evaluated.

Framing and Tailoring the Message

Birch posed a question from an audience member who wanted to know if any culturally tailored interventions to decrease sugar-sweetened beverage intake in specific racial or ethnic groups or in rural communities have been successful. Hecht noted that, based on responses provided during a focus group, parents may respond better to electronic promotion and electronic messaging (e.g., via phones, use of videos) than materials in written form. Siega-Riz added that messages need to be tailored to the culture and to the specific source of the problem.

Birch also asked the session speakers about tactics to target older siblings, caregivers, gatekeepers, and parents, as “children of this age do not make the initial decision to try a [sugar-sweetened beverage].” Story stated that we have to re-educate and increase the knowledge about limiting the consumption of 100 percent fruit juice. She also said that the message needs to get out that fruit-flavored drinks often have minimal or no actual fruit in them. Siega-Riz noted that to educate parents, translating the portion size into something meaningful is key, and consideration needs to be given as to how to provide clear messages to all caretakers of the child, including parents, grandparents, babysitters, and child care providers. Hecht thought potential messengers may be WIC staff and oral health care providers. In thinking about displacing juice in the diet, Hecht offered an anecdote. The head of a large child care conglomerate told her that when a center tried to make the switch to less juice and more water, parents felt as though they were not getting their money’s worth. Hecht suggested that a strategy to combat this negative perception would be to make it clear that the money is spent on something beneficial for the children, rather than focusing on the removal of the juice.

An audience member asked the session speakers about adding sugar labeling or warning labels to products and how that would affect promotion to parents in terms of what is in beverages. Gortmaker and Story both expressed their support of the additional information about added sugars to the product labels. They both thought that if the sugar-sweetened beverage taxation was based on the amount of sugar in beverages, this could lead to the industry responding by reformulating products to lower the amount of sugar. Gortmaker also noted that the recent challenges to the sugar-sweetened beverage excise taxes in the United States have helped to educate consumers about sugar-sweetened beverages.

Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
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Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 8
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 9
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 10
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 11
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 12
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 13
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 14
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 15
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 16
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 17
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 18
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 19
Suggested Citation:"2 Setting the Stage." National Academies of Sciences, Engineering, and Medicine. 2017. Strategies to Limit Sugar-Sweetened Beverage Consumption in Young Children: Proceedings of a Workshop. Washington, DC: The National Academies Press. doi: 10.17226/24910.
×
Page 20
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On June 21–22, 2017, the National Academies of Sciences, Engineering, and Medicine's Food and Nutrition Board convened a workshop in Washington, DC, to explore the range of policies and programs that exist at the federal, state, tribal, and local levels to limit sugar-sweetened beverage consumption in children birth to 5 years of age. Topics examined over the course of the 1.5-day workshop included prevalence and trends in beverage intake among young children; beverage intake guidelines applicable to the age range of interest; challenges and opportunities of influencing beverage consumption; the role of industry in beverage intake; and knowledge gaps and research needs. This publication summarizes the presentations and discussions from the workshop.

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