August 2009

Grant Results

SUMMARY

In 2006, researchers at the Harvard University School of Public Health produced two reports and three articles on the relation between sugar-sweetened beverages and obesity in children:

  • Sugar-Sweetened Beverages and Children's Health, a review of trends in sugar-sweetened beverage consumption among U.S. children and the scientific evidence about the effect of such consumption on their health.
  • Policies Affecting Access to Sugar-Sweetened Beverages and Schools: A Legal and Regulatory Review that looked at policies in all 50 states.

Key Findings
The two reports, written for the Robert Wood Johnson Foundation (RWJF) state:

  • Children's calorie intake from sugar-sweetened beverages has doubled since the mid-1970s, with children in 2001 ingesting more than 10 percent of their total daily calories from sugar-sweetened beverages.
  • Some 34 states—through legislation, regulation or a combination thereof—have created a state policy that required or recommended that schools adopt beverage standards more stringent than those set by the federal National School Lunch Program.

Recommendations

  • Children should consume mostly water and other unsweetened beverages, such as herbal tea and sodium-free seltzer water (with or without natural fruit flavoring). Other alternatives include skim or low-fat milk and 100 percent fruit juice diluted with water.

After the Grant
The three articles, published after the grant, appeared in the June 2, 2008, issue of Pediatrics, the Journal of the American Medical Association (June 27, 2008) and the American Journal of Public Health (April 2008). RWJF posted an abstract of the Pediatrics article on its Web site. See the Bibliography.

Funding
RWJF supported this solicited project with a grant of $74,755.

 See Grant Detail & Contact Information
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THE PROBLEM

Overweight is rapidly increasing among children and youth in the United States. According to the Centers for Disease Control and Prevention, between 1976 and 2004, obesity rates increased from 6.5 percent to 18.8 percent for children ages 6 to 11.

Children's consumption of sugar-sweetened beverages also has risen dramatically in that time period (Cullen et al., American Journal of Public Health, 92(9): 1475–1478, 2002). Although the causes of the obesity epidemic are many, there is evidence from a wide array of sources that implicates sugar-sweetened beverages as a potential cause.

As federal, state and local governments begin considering legislation to limit the availability of sugar-sweetened beverages in schools, policy-makers need more information regarding the effect of sugar-sweetened beverage consumption on children's health and the potential impact of laws aimed at curtailing their consumption in schools.

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RWJF STRATEGY

RWJF seeks to reverse the upward trend in childhood obesity by 2015. RWJF has developed three integrated strategies to reverse the childhood obesity epidemic: evidence, action and advocacy.

  • Evidence. Investments in building the evidence base will help ensure that the most promising efforts are replicated throughout the nation.
  • Action. RWJF's action strategy for communities and schools focuses on engaging partners at the local level, building coalitions and promoting the most promising approaches.
  • Advocacy. As RWJF staff learns from the evidence and action strategies, it shares results by educating leaders and investing in advocacy, building a broad national constituency for childhood obesity prevention.

This project is part of the evidence strategy.

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THE PROJECT

In 2006, researchers at the Harvard University School of Public Health produced two reports for RWJF staff on the relation between sugar-sweetened beverages and obesity in children:

  • Sugar-Sweetened Beverages and Children's Health. Based on a comprehensive literature review, the paper:
    • Examined trends in sugar-sweetened beverage consumption among U.S. children ages 2 to 18 since the mid-1970s.
    • Considered the scientific evidence regarding the effect of sugar-sweetened beverage consumption on the health of children.
    • Suggested alternatives to sugar-sweetened beverages.
  • Policies Affecting Access to Sugar-Sweetened Beverages and Schools: A Legal and Regulatory Review. The paper included:
    • A 50-state review of state laws, pending legislation and administrative actions from 2000 to early 2006.
    • An analysis of certain sociodemographic and political features of each state—for example, percentage of population that is obese, per-capita income, political party in control of legislature—and their possible association with state lawmakers' interest in adopting, or ability to adopt, sugar-sweetened beverage regulations.
    • Case studies of six school district-level policy initiatives that represented interesting local approaches. (See the Appendix for a list of the school districts.) The districts were diverse in several respects, including region, magnitude of the childhood obesity problem and the type and strength of local sugar-sweetened beverage policies.

      Investigators conducted semi-structured telephone interviews of 30 to 60 minutes with each of four people involved with nutrition policy from each of the six districts. Among those included:
      • Director of food and nutrition services.
      • Member of the superintendent's office.
      • School principal.
      • Leader from an outside organization with a vested interest in the district's beverage policy.
      • School nutritionist or health educator.
      • Parent.

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FINDINGS

From ''Sugar-Sweetened Beverages and Children's Health''

  • Calorie intake from sugar-sweetened beverages has doubled since the mid-1970s, with children in 2001 ingesting more than 10 percent of their total daily calories from sugar-sweetened beverages.

    Recent data through 2004 indicate further increases, and similar high levels of intake among different income and ethnic groups.

From ''Policies Affecting Access to Sugar-Sweetened Beverages and Schools: A Legal and Regulatory Review''

  • Thirty-four states—through legislation, regulation or a combination thereof—have created a state policy that required or recommended that schools adopt beverage standards more stringent that those set by the National School Lunch Program. (Some 16 states had no policies regarding sugar-sweetened beverages.)

    The National School Lunch Program is a federally assisted meal program operating in public and nonprofit private schools and residential child-care institutions.
  • Among the states with strong sugar-sweetened beverage policies, the predominant policy approach was first a mandate for such policies by the state legislature and then state agency administrative action to implement the mandate.
  • Strong and moderate sugar-sweetened beverage policies were significantly more likely to be present in states with:
    • A relatively high proportion of the population in metropolitan areas.
    • High per capita income.
    • A Democrat-controlled legislature.
    The states' rank on childhood obesity prevalence was not a statistically significant predictor of the strength of their sugar-sweetened beverage policies.
  • Local case studies revealed that districts with significant community support found it easier to adopt and enforce strong standards. However, there was wide variation in both substantive approaches and the process of policy creation and implementation.

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RECOMMENDATIONS

The investigators offered the following recommendation in Policies Affecting Access to Sugar-Sweetened Beverages and Schools: A Legal and Regulatory Review:

  • Children should consume mostly water and other unsweetened beverages, such as herbal tea and sodium-free seltzer water (with or without natural fruit flavoring). Other alternatives include skim or low-fat milk and 100 percent fruit juice diluted with water.

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CONCLUSIONS

The investigators based the following conclusions on their review of scientific evidence, as reported in Sugar-Sweetened Beverages and Children's Health.

  • Sugar-sweetened beverages provide excess calories that lead to excess weight gain.

    Evidence from randomized controlled feeding trials and longitudinal studies of children and adults show that sugar-sweetened beverage consumption adds to total caloric intake and increases mean body mass index (BMI) and incidence of obesity.
  • Sugar-sweetened beverage consumption is associated with early warning signs of diabetes in children and increased incidence of type 2 diabetes in adults.
  • Sugar-sweetened beverages cause dental decay.
  • Sugar-sweetened beverage consumption is associated with decreased milk consumption, and thus may interfere with adequate intake of calcium, vitamins and other nutrients, which may negatively affect development.

    Teenagers appear to be particularly at risk: although bone mass accrual peaks in early adolescence, children drink more sugar-sweetened beverages and less milk in their teen years.
  • Some sugar-sweetened beverages provide caffeine, which has been associated with poor sleep and anxiety in children.

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AFTER THE GRANT

The researchers wrote three articles based on the study. The articles appeared in the June 2, 2008, issue of Pediatrics, the Journal of the American Medical Association (June 27, 2008) and the American Journal of Public Health (April 2008). RWJF posted an abstract of the Pediatrics article on its Web site. See the Bibliography for details.

In July 2009, RWJF asked Web site visitors and subscribers to choose the most influential childhood obesity research for the past year. RWJF asked Web site visitors and subscribers to choose the most influential childhood obesity research for the past year. Over 900 people cast votes in the selection of the most influential childhood obesity articles from a list of 20.

The article, "Increasing Caloric Contribution From Sugar-Sweetened Beverages and 100% Fruit Juices Among US Children and Adolescents, 1988–2004," in Pediatrics was in the top 10.

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GRANT DETAILS & CONTACT INFORMATION

Project

Reviewing Consumption Trends of Sugar-Sweetened Beverages and their Role in Increasing Obesity

Grantee

Harvard University School of Public Health (Boston,  MA)

  • Amount: $ 74,755
    Dates: November 2005 to December 2006
    ID#:  055631

Contact

Steven L. Gortmaker
(617) 432-1029
sgortmak@hsph.harvard.edu

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APPENDICES


Appendix 1

(Current as of the time of the grant; provided by the grantee organization; not verified by RWJF.)

SCHOOL DISTRICTS SELECTED FOR CASE STUDIES

Boston Public Schools
Boston, Mass.

Boulder Valley School District
Boulder, Colo.

Iowa City Community School District
Iowa City, Iowa

Jefferson County School District
Jefferson County, Ky.

Nebo School District
Nebo, Utah

Philadelphia School District
Philadelphia, Pa.

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Mello MM, Pomeranz J and Moran P. "The Interplay of Public Health Law and Industry Self-regulation: The Case of Sugar-Sweetened Beverage Sales in Schools." American Journal of Public Health, 98(4): 595–604, 2008. Available online.

Perrin JM, Bloom SR and Gortmaker SL. "The Increase of Childhood Chronic Conditions in the United States." Journal of the American Medical Association, 297: 2755–2759, 2008. Extract available online.

Wang YS, Bleich SN and Gortmaker SL. "Increasing Caloric Contribution From Sugar-Sweetened Beverages and 100% Fruit Juices Among US Children and Adolescents, 1988–2004. Pediatrics, 121(6): e1604–e1614, 2008. Abstract available on RWJF online.

Reports

Gortmaker SL, Roberts A, Wang YC, Ludwig D. Sugar-Sweetened Beverages and Children's Health. Boston: Harvard University School of Public Health, 2007. Unpublished.

Moran P, Pomeranz J, Mello M. Policies Affecting Access to Sugar-Sweetened Beverages and Schools: A Legal and Regulatory Review. Boston: Harvard University School of Public Health, 2006. Unpublished.

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Report prepared by: Robert Crum
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: C. Tracy Orleans