7
Reflections and an Exploration of Gaps and Opportunities
The last session of the workshop reflected on and summarized key messages from the preceding sessions, explored the evidence and research needs that exist, and considered opportunities to fill the identified gaps. To achieve these objectives, Virginia Stallings, professor of pediatrics at the University of Pennsylvania Perelman School of Medicine and director of the Nutrition Center at the Children’s Hospital of Philadelphia, was charged with providing her reflections on the material that had been presented over the course of the day and a half workshop. She then moderated a panel discussion, which expanded to a facilitated discussion toward the end of the session. Panelists included Richard Black, Stephen Daniels, Marlene Schwartz, and Mary Story. At the end of the discussion, Karen Weber Cullen provided brief, concluding remarks.
REFLECTIONS ON THE WORKSHOP1
To begin her reflections, Stallings reminded the audience of the workshop’s age group of interest—children from birth to 5 years of age. She thought the broad information that had been presented during the workshop, which encompassed older children and adults, showcased that “there is so little information and so little specificity” for infants, toddlers, and preschool-age children. Young children are not customers and are completely dependent on what is served or offered to them. Stallings perceived this as a strength of focusing on children 5 years of age and younger, and is
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1 This section summarizes information presented by Virginia Stallings.
something that could be leveraged. Young children are provided beverages in settings beyond just the home environment. As such, Stallings emphasized the importance of engaging not only parents, but also other caretakers across the spectrum of child care settings.
In discussing the role of federal nutrition programs, Stallings pointed to changes to the food packages offered through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as school meals and competitive food policies, as examples of improvements that have been made. From her perspective, similar opportunities for change currently exist for the Supplemental Nutrition Assistance Program and, to a lesser extent, the Child and Adult Care Feeding Program (CACFP). Stallings also raised the issue of a lack of federal policy for children ranging from birth to 24 months of age. She noted that this gap has been primarily filled by public statements on infant and child feeding practices from the American Academy of Pediatrics. The gap has the potential to be filled through the work of the B-24 Project, and it is within the authority of the 2020–2025 Dietary Guidelines for Americans to provide guidance for this age group.
Identifying portion size as a key issue, Stallings said, “There is an inherent difficulty in portion sizes with liquids that we have to think about. You can drink a lot of calories very fast.” One of the challenges related to portion size mentioned by Stallings is that cups, even sippy cups, are often larger than 4 ounces. Another consideration she raised was the role of economic value and incentives to consume more (e.g., free refills), particularly for those in poverty.
Stallings then reflected on specific types of beverages. She suggested that while whole fruit is preferential, 100 percent juice still has a place in the dietary pattern when provided within age-appropriate portion sizes. Stallings expressed that the approach to handling 100 percent juice in the diet merits its own separate discussions. There are also issues related to drinking water, both broadly and as they specifically relate to this age group. For example, there is currently ambiguity regarding whether or not water should be given to children younger than 12 months of age. Other issues Stallings highlighted included “having safe water, creating a culture in the United States where water is the next beverage that you might give young children,” and differentiating between plain and flavored non-caloric water. In considering beverage consumption of young children from a broad perspective, Stallings offered, “There are some things that we, as a culture, recognize are appropriate for children of this age. For example, we believe a few things are adult beverages. Alcohol, coffee—generally those are not things you are going to want someone under 5 to have.”
To conclude, Stallings remarked that there are opportunities to recast the goal of limiting consumption of sugar-sweetened beverages by young children into a “public health step and message that all parents and com-
munities and even the government can be proud of.” She noted there are several examples of initiatives that have communicated public health messages to families, and pointed to examples such as choking hazards in first foods and sleeping positions for the prevention of sudden infant death syndrome. To achieve a similar effect with sugar-sweetened beverages, Stallings urged the audience to think through ways to define the message, work on building a strong evidence base, enhance cultural awareness, and become relevant to individuals across all socioeconomic groups. She also pointed out the range of roles that government, from local to federal, could play by using tools such as executive orders and City Council decisions that include revising regulations around the availability of sugar-sweetened beverages to participants in nutrition assistance programs and the importance of looking to the food industry to develop new products. “Stakeholders, partners, community—all of those—are really essential to getting this done,” she said. Stallings said that it is a goal to bring the birth to 24-month age group into the public health domain and reduce sugar-sweetened beverage consumption as a part of public health programs.
PANEL DISCUSSION
After her prepared remarks, Stallings moderated a panel discussion with Black, Daniels, Schwartz, and Story. The discussed topics were initially drawn from brief statements made by each of the panelists and from questions provided by the audience in the facilitated discussion format. Toward the end of the session, questions were taken directly from the audience members in an active question-and-answer format. The sections below summarize the topics that emerged over the course of the panel discussion.
Brief Statements from Each of the Panelists
To begin, each panelist gave a brief statement about what they perceived were key topic areas for discussion. In reflecting on the Session 1 presentations and in citing a recent dietary intake analysis among children 2 to 19 years of age in the United States (Rosinger et al., 2017), Story indicated that sugar-sweetened beverage consumption is pervasive among youths and a need exists to intervene while children are young. To target children from birth to 5 years of age, Story suggested that the focus needs to be on juice-flavored drinks (also known as juice drinks, juice beverages, nectars, fruit drinks) that are not 100 percent fruit juice.
During his remarks, Black emphasized two concepts. First, he discussed sugar-sweetened beverage taxes, cautioning against trying to regulate sweetness, and suggesting that it would be ideal to target the amount of added
sugars. Second, he highlighted the importance of identifying partners, including those who are “not the usual suspects.”
A dietary pattern approach is needed to help guide how to optimize intake, Daniels reflected, because young children are currently consuming an excess of calories while not consuming sufficient amounts of many nutrients. He also offered that one strategy to consider is finding better ways to implement guidelines.
Schwartz discussed research needs related to 100 percent juice and flavored milk. She suggested that there is “an empirical question about what would happen if we really recommended that [children] not drink 100 percent fruit juice up until age 5,” and she recognized that there is uncertainty about the possible forms of juice substitutes that parents or caregivers might choose. Her group recently conducted a 2-year study on the effects of removing flavored milk from schools and found consumption of plain milk increased over time (Schwartz et al., 2017). Additional research is needed, she noted, especially on the longitudinal effect of removing flavored milk from preschools, kindergartens, and elementary schools on plain milk intake.
Fruit Drinks and 100 Percent Fruit Juice
Among the challenges discussed by the panel was the terminology used to characterize fruit drinks that are less than 100 percent juice. Schwartz suggested that describing such products as fruit drinks can lead to confusion since the term fruit is used, a sentiment shared by Story. Daniels questioned whether the term fruit might be reserved exclusively to describe 100 percent juice. One concern that could result from that kind of proposal, Black suggested, is that some specific terminologies that are used for flavor descriptions (e.g., fruity) do not meet the requirement for content claims as set forth by U.S. regulatory agencies. Instead of attempting to change the terminology, he proposed mandating that any fruit image be proportionate to the fruit content of the product, an approach that is currently being used in Canada.
A member of the audience noted that for a product to be considered “juice,” it is required by law to be 100 percent juice, whereas a juice drink requires minimal juice content, but is required to put the percent juice on the container. Schwartz noted that this is what was so challenging about trying to teach parents the difference—it requires reading the ingredient list to understand the difference. She showed an example of how this information is labeled on a selection of products. Recognizing the complexities inherent in describing fruit drinks, Story advanced the notion of organizing a meeting or taskforce to consider how best to specify the description
of these products and then leverage that as a means toward limiting their consumption by young children.
Dietary Intake of Infants and Longitudinal Data
The panel discussed the role and need for data, particularly in infants. Black wondered if it was necessary to collect data on children from birth to 6 months of age, as it is presumed that infants do not consume sugar-sweetened beverages. Stallings contested this idea, noting that “sometimes the prioritization or the imperative nature of change comes out of finding out something we [did not] believe was happening is happening.” Daniels also challenged Black’s comment, stating that longitudinal data are necessary in order to better understand how taste preferences develop in context of parental feeding habits and behaviors. With respect to longitudinal data, an audience member noted that the Food and Nutrition Service is currently conducting the WIC Infant and Toddler Feeding Practices Study II, and published its first report at the beginning of January (May et al., 2017).
A member of the audience asked if there were longitudinal data on the long-term effects of restricting young children’s access to sugar-sweetened beverages; for instance, would young children drink more if they had the liberty to make their own drink selections? Leann Birch, moderator of the first session of the workshop, commented from the audience that there are analyses of data from the follow-up to the Infant Feeding Practices Study II (IFPS II) indicating that intake of sugar-sweetened beverages during infancy increased the likelihood of sugar-sweetened beverage consumption at 6 years of age. On the topic of restrictions, Black wondered if anything could be learned by the messages of industries that currently have such restrictions (e.g., alcohol). Stallings repeated the sentiment she expressed in her reflections—that there are beverages that are culturally accepted as inappropriate for young children—and thought this may be an area in which partnerships could potentially be explored.
Developing Effective Messages and Promoting Change Within Specific Population Groups
The panel also discussed ideas about developing effective messages. Messages about growth, health, and development, such as those being used to market toddler drinks, are significant to parents of young children, noted Schwartz. She later commented that the messaging about when to introduce water into an infant’s diet needs to be clarified and done in such a way that is “very deliberate and intentional.” Story noted that tailoring the message is crucial to fostering change within a particular population group. As an example, she pointed to a Session 4 presentation, in which
Henrietta Sandoval-Soland described using the phrase “water is sacred” in the Navajo Nation.
Black thought celebrities and cutting-edge approaches with social media could be leveraged. In such engagement, he suggested it is important to communicate a message that allows people to identify what products they want, rather than focusing on the products they are not supposed to have. In response to Black’s comments, Stallings drew a parallel to the Got Milk? campaign. Later in the discussions, Black offered that “I [do not] think it’s a big leap to get [celebrities] who are passionate about nutrition, broadly speaking, to say you can have a really big impact if you focus over here and work with us on this other aspect.” A member of the audience commented that there could be learning and evidence from the U.S. Food and Drug Administration’s tobacco control Real Cost campaign. The audience member noted that some of the focus group feedback on the subsequent Fresh Empire campaign emphasized the importance of the authenticity of the messenger. Another example the audience member suggested considering is the Truth campaign, which was funded by the tobacco Master Settlement Agreement and leveraged social media. Drawing on the audience member’s point, Christina Hecht emphasized the importance of the funding required for advertisement and questioned who would be the champion for water. She noted that this presents an opportunity for creativity.
The discussion also explored the concept of food as a reward. Black suggested that sugar-sweetened beverages may serve as an accessible treat that low-income families can afford, and that strategies to reduce sugar-sweetened beverages need to provide opportunities for treats with less added sugars. Expanding on this idea, Stallings offered that one of the challenges is that food and beverages are part of our ceremonies, celebrations, and culture. Daniels added that he thought “we may not be challenging the concept of food as a reward enough.” He continued by suggesting that a better understanding of food as a reward paradigm “would allow us to think about better strategies to deal with it.” One idea would be to determine how to redirect rewards toward something that promotes child development, such as reading, Stallings proposed.
Leveraging the Child and Adult Feeding Program
An audience member asked the panelists whether states or cities should be providing more support to the programs that participate in CACFP to improve limitations of sugar-sweetened beverages. Story said that providing more support for such programs was a good idea. Black expressed that it is essential for such programs to agree on the measurable outcomes from the beginning and track efficacy. In revisiting this concept later in the discussion, an audience member made several points regarding CACFP and
the potential for partnerships. She noted that CACFP is a suitable partner because it serves half of all early care and education settings and that approximately three-quarters of children served are from low-income families. CACFP has a best practice rule, taking effect in October 2017, which will reduce sugar-sweetened beverages. The audience member also suggested that partnerships between state and localities and CACFP could be beneficial when it comes to changing policies.
Milk Alternatives
An audience member asked the panel about educating the public about milk alternatives (e.g., soy milk, almond milk, coconut milk). Daniels questioned the use of milk alternatives among children 1 to 5 years of age, and expressed that he thought moving children away from cow’s milk consumption was a mistake. While cow’s milk protein allergies exist, he noted, they are relatively uncommon. Black wondered if this product category, at about 6 grams of sugar per serving, had a high enough sugar content to make it worthwhile to limit. Later in the session, Esa Davis, moderator of the second session of the workshop, suggested that there might be misperceptions about the prevalence of lactose intolerance and milk allergies that are absorbed by the community at large.
Engaging Health Care Providers
The panel also discussed strategies to help pediatricians, family practice physicians, oral health providers, and other health care providers reinforce the message regarding sugar-sweetened beverages. Daniels described nutrition education for medical students and residents as “woefully inadequate.” Later, Ferree described the efforts on this front by the Alliance for a Healthier Generation, which include working alongside the the American Academy of Pediatrics, the Bipartisan Policy Center, and a number of other partners to transform the training systems used not only in medical schools, but also in all affiliated health care professional training systems. From the audience, Leann Birch emphasized the role of and opportunities to use WIC as a conduit for reaching parents.
CLOSING REMARKS
In her closing remarks, Cullen revisited the concept she presented to open the workshop. She noted that over the course of a day, a child may be in the care of a variety of caretakers in various surroundings, and that various influences affect what beverages are offered to and consumed by the child. She thought the strategies highlighted over the course of
this workshop addressed the breadth of approaches currently available to limit sugar-sweetened beverage consumption. Reiterating points made during the preceding panel discussion, Cullen emphasized the importance of identifying a champion or someone with authentic representation of the different groups in order to effectively deliver and tailor the message. She also touched on the role of nutrition education through federal programs. Evidence gaps currently exist, Cullen noted, and include longitudinal studies of dietary patterns of children from birth to 5 years of age and studies exploring the effect of marketing on young children’s consumption of sugar-sweetened beverages. She emphasized the role of family, but explained that misperceptions, behaviors, and beliefs may be barriers to limiting sugar-sweetened beverages in homes. Cullen suggested that a need exists to reduce these barriers and social norms around sugar-sweetened beverages.
