Jean A. Welsh, MPH, RNSusan Anderson, MS, RDWinifred King, PhDBettylou Sherry, PhD

CDC State Partners MeetingNovember 13, 2008

Reduction of Sugar-Sweetened Beverage Consumption

Session ObjectivesSession ObjectivesPresentationPresentation Describe why reduction of SSBs is a CDC priority Describe why reduction of SSBs is a CDC priority Highlight federal, state, and local initiatives to Highlight federal, state, and local initiatives to

reduce SSB consumptionreduce SSB consumption Summarize evidence of effectiveness of Summarize evidence of effectiveness of

interventions to reduce SSB consumptioninterventions to reduce SSB consumption Present proposed key Strategies & Action Steps Present proposed key Strategies & Action Steps Introduce plans for the Introduce plans for the CDC Guide to Reducing CDC Guide to Reducing

Sugar-Sweetened Beverage ConsumptionSugar-Sweetened Beverage ConsumptionFollow-up DiscussionFollow-up Discussion Elicit input from state partners & colleagues Elicit input from state partners & colleagues

regarding:regarding:– Plans for the CDC GuidePlans for the CDC Guide– Future collaboration Future collaboration

SSB Definition and SSB Definition and Consumption TrendsConsumption Trends

What are Sugar-Sweetened What are Sugar-Sweetened Beverages (SSBs)?Beverages (SSBs)?

Beverages with sugar added:Beverages with sugar added:– during industry processing during industry processing – during preparation by consumer during preparation by consumer

Includes: Non-diet carbonated soft drinks Includes: Non-diet carbonated soft drinks (soda or pop), fruit drinks/ades, teas and (soda or pop), fruit drinks/ades, teas and coffees, sports drinks and flavored milkscoffees, sports drinks and flavored milks

Does not include 100% juiceDoes not include 100% juice

Added SugarsAdded Sugars

Source: USDA Dietary Guidelines for Americans, 2005

Common Beverage Common Beverage SweetenersSweetenersSucroseSucrose naturally occurring naturally occurring 50% fructose, 50% glucose 50% fructose, 50% glucose

HFCSHFCS Conversion of glucose from Conversion of glucose from

corn to fructosecorn to fructose Product combined with glucose Product combined with glucose

in varying proportionsin varying proportions– 42% fructose42% fructose

Processed foodsProcessed foods– 55% fructose55% fructose

BeveragesBeverages

Less expensiveLess expensive than sucrose than sucrose

HFCS: A Sugar By Any Other Name…

Source: HFCSfacts.com

SSBs largest single source of SSBs largest single source of calories in the US dietcalories in the US diet– 1965: 50 kcal/day1965: 50 kcal/day– Today: children/youth 224 kcal/dayToday: children/youth 224 kcal/day

Increases:Increases: prevalenceprevalence frequencyfrequency amountamount

SSB Consumption TrendsSSB Consumption Trends

Change in Caloric Intake Change in Caloric Intake from SSB by Agefrom SSB by Age

Source: Nielsen and Popkin AJPM, 2004

0

2

4

6

8

10

12

14

77-78 89-91 94-96 99-01

Pe

rce

nt

da

ily

ca

lori

e i

nta

ke 2-18 y

19-39 y

40-59 y

>=60 y

Contextual FactorsContextual Factors

JIU#4648623

Factors Associated with Factors Associated with SSB ConsumptionSSB Consumption

KnowledgeKnowledge

Increased advertising and marketingIncreased advertising and marketing

Increased portion sizesIncreased portion sizes

Increased fast foodsIncreased fast foods

Increased TV watchingIncreased TV watching

Parenting practices and home environmentParenting practices and home environment

School environmentSchool environment

Preference for sweet tastePreference for sweet taste

School-based nutrition School-based nutrition

education programseducation programs

reduced SSB reduced SSB intakeintake

(James, 2006; Contento, 2007, (James, 2006; Contento, 2007, Sichieri, 2007)Sichieri, 2007)

KnowledgeKnowledge

Increased advertising and Increased advertising and marketingmarketing

Hundreds of new Hundreds of new beverages introducedbeverages introducedeach year (ERS/USDA, 2005)each year (ERS/USDA, 2005)

$100’s millions for $100’s millions for advertising & promotion of SSBsadvertising & promotion of SSBs

Advertising to children/youth Advertising to children/youth influences their preferences & requests influences their preferences & requests for high calorie, low-nutrient-dense for high calorie, low-nutrient-dense food and beverages (IOM, 2005)food and beverages (IOM, 2005)

Increased portion sizesIncreased portion sizes

Since the 1960s the industry has Since the 1960s the industry has increased the single-serving size from increased the single-serving size from a standard 6-½-ounce bottle to a 20- a standard 6-½-ounce bottle to a 20- ounce bottle. ounce bottle.

Serving a larger portion of a beverageServing a larger portion of a beverage

increases beverage consumptionincreases beverage consumption With increased calorie-containing With increased calorie-containing

beverages, energy intake increasesbeverages, energy intake increases(Flood, 2006)(Flood, 2006)

Increased Fast FoodsIncreased Fast Foods

SSB consumption increases for SSB consumption increases for both boys and girls as weekly both boys and girls as weekly fast fast

food consumption food consumption

increases (French, 2001)increases (French, 2001)

Increased TV WatchingIncreased TV Watching

Depending on their age, youth view between 12 and 21 commercials for food or beverages every day (RWJF, 2008)

For each 1-hour increment of TV viewing per For each 1-hour increment of TV viewing per day, SSB intakes were shown to increase day, SSB intakes were shown to increase 0.06 servings0.06 servings

(Miller, 2008).(Miller, 2008).

Parenting practices & Parenting practices & home environmenthome environment

Permissive parentingPermissive parenting– Permissiveness to requests for SSBs Permissiveness to requests for SSBs

and catering to demand of children and catering to demand of children

correlated with children’s SSB consumption (Haerens, 2008)correlated with children’s SSB consumption (Haerens, 2008) Modeling of dietary behaviorModeling of dietary behavior

– Children’s consumption strongly correlated with their Children’s consumption strongly correlated with their parents, particularly their mother’s (Vereecken, 2004)parents, particularly their mother’s (Vereecken, 2004)

– Youth whose parents drink SSBs are nearly 3 x more likely Youth whose parents drink SSBs are nearly 3 x more likely to drink SSBs to drink SSBs > > 5x/week (Grimm, 2004)5x/week (Grimm, 2004)

Access to SSBsAccess to SSBs– Home source of majority of SSBs consumed (Wang, 2008)Home source of majority of SSBs consumed (Wang, 2008)

School environmentSchool environment AccessAccess

– 33% elementary, 71% middle and 89% HS have a vending 33% elementary, 71% middle and 89% HS have a vending machine, school canteen, etc. where SSBs can be machine, school canteen, etc. where SSBs can be purchased (SHPPS, 2006)purchased (SHPPS, 2006)

– 90% schools offer a la carte lunch (School Nutrition Dietary 90% schools offer a la carte lunch (School Nutrition Dietary

Assessment Study, 2001).Assessment Study, 2001). – School lunch consumers- 1/3 < sugar (Cullen, 2004)School lunch consumers- 1/3 < sugar (Cullen, 2004)

Pouring contractsPouring contracts– Long-term agreement between supplier and schools Long-term agreement between supplier and schools

whereby schools earn income in proportion to school whereby schools earn income in proportion to school beverage salesbeverage sales

– Most students (67% in middle and 83% in high school) are Most students (67% in middle and 83% in high school) are in schools that have a contract with a bottler (Johnston, in schools that have a contract with a bottler (Johnston, 2007)2007)

Advertising & promotionAdvertising & promotion– Advertising Advertising with pouring contracts (Probart, 2006) with pouring contracts (Probart, 2006)

Sweet Taste PreferenceSweet Taste Preference

Begins en uteroBegins en utero Taste preference importantTaste preference important

in decision to consume SSBsin decision to consume SSBs (Grimm, 2004)(Grimm, 2004) Sugar sweetness, when accompanied Sugar sweetness, when accompanied

by calories, may overwhelm the by calories, may overwhelm the body’s physiological satiety body’s physiological satiety mechanisms, leading to overeating mechanisms, leading to overeating (Rodin, 1975; (Rodin, 1975; Blundell et al., 1994; Blundell et al., 1994; Blundell and Green, 1996).Blundell and Green, 1996).

SSBs and Health SSBs and Health OutcomesOutcomes

SSB Consumption and SSB Consumption and ObesityObesity

Source: Johnson, R. J et al. A m J Clin Nutr 2007;86:899-906

Studies: SSBs and Energy Studies: SSBs and Energy Intake and WeightIntake and Weight

Source: Vartanian et al, AJPH, 2007

SSBs & Energy IntakeSSBs & Energy Intake PositivePositive NullNull InconsistentInconsistent

Cross-SectionalCross-Sectional 1010 11 11

LongitudinalLongitudinal 55 -- --

Short-term experimentalShort-term experimental 55 55 22

Long-term experimentalLong-term experimental 44 -- --

SSBs & WeightSSBs & Weight PositivePositive NullNull InconsistentInconsistent

Cross-SectionalCross-Sectional 1111 1111 --

LongitudinalLongitudinal 55 55 11

Long-term experimentalLong-term experimental 44 22 --

SSBs and Energy SSBs and Energy Intake/WeightIntake/WeightSummary of findingsSummary of findings Effect size small, highly variable by Effect size small, highly variable by

outcome measure outcome measure Effect sizes largest in experimental vs Effect sizes largest in experimental vs

cross-sectional studiescross-sectional studies– WomenWomen– AdultsAdults– Studies of carbonated sodaStudies of carbonated soda– Studies not funded by food industryStudies not funded by food industry

Source: Vartanian LR, et al. AJPH 2007

Biological Mechanisms: Biological Mechanisms: SSBs and WeightSSBs and Weight

Preference for sweet tastePreference for sweet taste Glycemic responseGlycemic response Liquid calories, failure to compensate Liquid calories, failure to compensate

for excess energy intakefor excess energy intake Effect of fructose metabolism on Effect of fructose metabolism on

satiety hormonessatiety hormones

SSB energy intake weight+ +

Other Health OutcomesOther Health Outcomes

Dental cariesDental caries Type 2 diabetesType 2 diabetes Liver disease- NAFLDLiver disease- NAFLD DyslipidemiaDyslipidemia Decreased bone densityDecreased bone density Nutrient displacementNutrient displacement

Public Health Public Health InterventionsInterventions

Social Ecological ModelSocial Ecological Model

Multi-level intervention: Society, Community, Organizational, Multi-level intervention: Society, Community, Organizational, Interpersonal and IndividualInterpersonal and Individual Multiple strategies: Policy, environment, information-basedMultiple strategies: Policy, environment, information-based

Federal LegislationFederal Legislation

School AccessSchool Access USDA National School Food ProgramsUSDA National School Food Programs

National Wellness Committees & National Wellness Committees & PoliciesPolicies

WIC Reauthorization ActWIC Reauthorization Act

LabelingLabeling FDAFDA

AdvertisingAdvertising FTCFTC

State Legislation: State Legislation: SchoolsSchools Elimination of all beverages that contain caloric Elimination of all beverages that contain caloric

sweeteners except milk - Kentucky, Tennessee, sweeteners except milk - Kentucky, Tennessee, LouisianaLouisiana

Limiting marketing to only Limiting marketing to only healthyhealthy beverages - beverages - Alabama.Alabama.

Adjusting the container size for the beverage Adjusting the container size for the beverage type and the age of the targeted consumers - type and the age of the targeted consumers - Alabama and Kentucky Alabama and Kentucky

Prohibits use of beverages as reward or Prohibits use of beverages as reward or punishment - Arkansas punishment - Arkansas

Ensuring availability of Ensuring availability of healthfulhealthful beverages (i.e. beverages (i.e. bottled water or low-fat milk) whenever bottled water or low-fat milk) whenever beverages are offered or sold - 17 % of statebeverages are offered or sold - 17 % of state

Sources: Mello, Am J Public Health. 2008 Apr;98(4):595-604

http://www.schoolbeverages.com/research--faqs/school-wellness-policies/ http://www.schoolbeverages.com/research--faqs/school-wellness-policies/ download.aspx?id=59;download.aspx?id=59;

State Legislation: State Legislation: ChildcareChildcare

Limit SSBs for allLimit SSBs for all– NMNM

Limiting SSBs for infants < 12 monthsLimiting SSBs for infants < 12 months– OROR

Prohibits giving foods with corn syrup to Prohibits giving foods with corn syrup to infantsinfants– CACA

SSBs served on limited occasionsSSBs served on limited occasions– GA, NC, NVGA, NC, NV

No fruit ades, drinks, soft drinks, or No fruit ades, drinks, soft drinks, or powders served or accessible to childrenpowders served or accessible to children– ININ

Source: Benjamin et al., BMC Public Health, 2008

Local Policies and Local Policies and GuidelinesGuidelines

School Beverage Guidelines, Alliance for School Beverage Guidelines, Alliance for Healthier GenerationsHealthier Generations– Voluntary guidelines between schools and their Voluntary guidelines between schools and their

supplierssuppliers– Restrict beverage sales to water, low-fat milk, 100% Restrict beverage sales to water, low-fat milk, 100%

juice; plus sports drinks and diet sodas in high schooljuice; plus sports drinks and diet sodas in high school Los Angeles Unified School DistrictLos Angeles Unified School District

– prohibits the sale of drinking water with additives other prohibits the sale of drinking water with additives other than those normally added to tap water;than those normally added to tap water;

– also prohibits milk products with > 8 grams (32 also prohibits milk products with > 8 grams (32 calories) of added sweetener per 8 oz or are calories) of added sweetener per 8 oz or are sweetened with artificial sweetener. sweetened with artificial sweetener.

Mississippi middle schoolMississippi middle school– students are allowed to bring water into the classroom.students are allowed to bring water into the classroom.

Effectiveness of Effectiveness of InterventionsInterventions

Literature reviewLiterature review No reviews or meta-analysesNo reviews or meta-analyses 13 studies with SSB as an outcome, 12 reduced SSBs13 studies with SSB as an outcome, 12 reduced SSBs

TargetsTargets Children, ages 1 to 18 yChildren, ages 1 to 18 y

SettingsSettings Schools: middle & high school (5); Schools: middle & high school (5); Community-based: homes (2); community (5)Community-based: homes (2); community (5) Health care setting (1)Health care setting (1)

Intervention strategiesIntervention strategies Policy component (0)Policy component (0) Education only (6)Education only (6) Environmental change only (0)Environmental change only (0) Parental involvement (5) Parental involvement (5)

Evidence GapsEvidence Gaps

Limited studies, issues of:Limited studies, issues of:– GeneralizabilityGeneralizability– ReliabilityReliability– FeasibilityFeasibility– Long-term impactLong-term impact

Lack of program impact evaluationsLack of program impact evaluations Importance of contextual factorsImportance of contextual factors Effect of replacement with “healthy” Effect of replacement with “healthy”

alternativealternative

Expanding the Evidence Expanding the Evidence BaseBase

Need systematic way to evaluate Need systematic way to evaluate health behavior interventionshealth behavior interventions

RE-AIMRE-AIM– RReach into the target population each into the target population – EEfficacy or effectiveness fficacy or effectiveness – AAdoption by target settings or institutions doption by target settings or institutions – IImplementation—consistency of delivery mplementation—consistency of delivery

of intervention of intervention – MMaintenance of intervention effects in aintenance of intervention effects in

individuals and populations over time. individuals and populations over time.

Source: re-aim.org

Strategies & Action Steps

““Healthy” Alternative?Healthy” Alternative? *Water*Water *1% or skim milk*1% or skim milk *100% fruit juice*100% fruit juice Sports drinks?Sports drinks? Diet drinks?Diet drinks?

Community-based:Community-based: 1. Promote access to and consumption of 1. Promote access to and consumption of

quality drinking waterquality drinking water

RationaleRationale Refreshing calorie-free alternativeRefreshing calorie-free alternative Substituting SSBs with water associated with Substituting SSBs with water associated with

↓ ↓ total energy intake (Wang, 2008)total energy intake (Wang, 2008) Quality drinking water not always readily accessibleQuality drinking water not always readily accessible

EffectivenessEffectiveness??

Potential Action StepsPotential Action Steps Ensure free access to quality drinking water in all public Ensure free access to quality drinking water in all public

facilities, including schools, parks, playgrounds, worksites, facilities, including schools, parks, playgrounds, worksites, etc.etc.

Ensure quality, potable drinking water in all households Ensure quality, potable drinking water in all households served by community water systemsserved by community water systems

Community-based:Community-based:2. Support the establishment and maintenance 2. Support the establishment and maintenance

of a nutritionally healthy home environmentof a nutritionally healthy home environment

Rationale Rationale Homes where eating behaviors adopted by children are Homes where eating behaviors adopted by children are

modeledmodeled Parenting behaviors & SSB consumption Parenting behaviors & SSB consumption

associated with children’s consumptionassociated with children’s consumption Home is the source of most SSBs consumedHome is the source of most SSBs consumed Fast food & TV associated with SSBsFast food & TV associated with SSBs

EffectivenessEffectiveness HIKCUPS study showed that dietary changes aimed at parents HIKCUPS study showed that dietary changes aimed at parents

can improve diets of young children (Burrow, 2008)can improve diets of young children (Burrow, 2008)

Potential Action StepsPotential Action Steps Offer training to build parenting skills related to child feeding Offer training to build parenting skills related to child feeding

practices in locations easily accessed by adults, i.e worksites, practices in locations easily accessed by adults, i.e worksites, places of worshipplaces of worship

Support initiatives that encourage families to prepare and eat Support initiatives that encourage families to prepare and eat more meals at home and to limit time spent watching TV.more meals at home and to limit time spent watching TV.

Community-based:Community-based:3. Early intervention to establish healthy 3. Early intervention to establish healthy

beverage consumption patternsbeverage consumption patterns

Rationale Rationale Eating behaviors established early in childhood, Eating behaviors established early in childhood,

track into adulthoodtrack into adulthood ~74% of kids 3 to 6 y attend non-parental care~74% of kids 3 to 6 y attend non-parental care 7 states have policies that restrict SSBs in child cares7 states have policies that restrict SSBs in child cares

Effectiveness`Effectiveness` ? Effectiveness of child care-based interventions? Effectiveness of child care-based interventions

Potential Action StepsPotential Action Steps Provide assistance & support to guide the development Provide assistance & support to guide the development

and maintenance of healthy nutrition environment in child and maintenance of healthy nutrition environment in child carescares

Utilize state/local licensing requirements to ensure that Utilize state/local licensing requirements to ensure that child care staff are provided with essential nutrition child care staff are provided with essential nutrition educationeducation

Provide nutrition education for parents through day caresProvide nutrition education for parents through day cares

Community-based:Community-based: 4. Minimize the impact of advertising and 4. Minimize the impact of advertising and

promotion of SSBspromotion of SSBs

RationaleRationale Beverage industry $$ advertising and promoting SSBs. Beverage industry $$ advertising and promoting SSBs.

AmongAmong ads viewed by children, 99% beverages high in added sugar

Intensive advertising influences child & youth preferences Intensive advertising influences child & youth preferences & & requests for high calorie and low-nutrient-dense requests for high calorie and low-nutrient-dense food/beverages food/beverages

EffectivenessEffectiveness ? ?

Potential Action StepsPotential Action Steps Advocate with state and local policy makers to restrict Advocate with state and local policy makers to restrict

advertising of SSBs aimed at childrenadvertising of SSBs aimed at children Advocate with the beverage industry to promote beverage Advocate with the beverage industry to promote beverage

alternatives that help meet nutrient needs, such as low-fat alternatives that help meet nutrient needs, such as low-fat milk, 100% juice, and water in place of SSBs milk, 100% juice, and water in place of SSBs

Provide media literacy training, particularly for children.Provide media literacy training, particularly for children.

School-based:School-based:1.1. Minimize access to SSBs; promote healthy Minimize access to SSBs; promote healthy

optionsoptionsRationale Rationale Many have access to SSBs in school, even during lunchMany have access to SSBs in school, even during lunch

EffectivenessEffectiveness Alliance for Healthier Generation: 58% fewer Alliance for Healthier Generation: 58% fewer

calories calories shipped 2004 & 2007-08 shipped 2004 & 2007-08 ((www.healthiergeneration.org)

Zuni Diabetes Prevention Project: replacing SSBs Zuni Diabetes Prevention Project: replacing SSBs with water/diet drinks stopped SSB consumption in school with water/diet drinks stopped SSB consumption in school (Ritenbaugh, 2003)(Ritenbaugh, 2003)

Energy content labels, promotion of diet drinks on vending Energy content labels, promotion of diet drinks on vending machines machines sales, primarily diet (Bergen, 2006) sales, primarily diet (Bergen, 2006)

Potential Action StepsPotential Action Steps Develop policies that eliminate sale of SSBs at schoolDevelop policies that eliminate sale of SSBs at school Redefine or eliminate beverage “Pouring Contracts”. Redefine or eliminate beverage “Pouring Contracts”. Ensure that quality drinking water is readily accessibleEnsure that quality drinking water is readily accessible

Photo: www.healthier generation.org

School-based:School-based: 22. . Eliminate advertising of SSBs and its Eliminate advertising of SSBs and its

effect on childreneffect on childrenRationaleRationale Most students are in schools that have a contract with a Most students are in schools that have a contract with a

bottler bottler Promotion of SSBs is greater in schools that have Promotion of SSBs is greater in schools that have

beverage pouring contracts with suppliersbeverage pouring contracts with suppliers

EffectivenessEffectiveness??

Potential Action StepsPotential Action Steps Eliminate promotion and advertisements of SSBs in Eliminate promotion and advertisements of SSBs in

schools. Explore options for replacing them with ads for schools. Explore options for replacing them with ads for beverages that provide nutrients that tend to be deficient beverages that provide nutrients that tend to be deficient in the diets of children and adolescents. in the diets of children and adolescents.

Provide media literacy training for studentsProvide media literacy training for students

School-based:School-based: 33. . Provide nutrition education for students Provide nutrition education for students

and teachersand teachers

Rationale Rationale Education is important tool for behavior change Education is important tool for behavior change Important to have supportive environmentImportant to have supportive environmentEffectivenessEffectiveness Studies among students in Brazil, England and Studies among students in Brazil, England and

U.S. have shown the a nutrition education U.S. have shown the a nutrition education focused intervention could reduce SSBs focused intervention could reduce SSBs

Potential Action StepsPotential Action Steps Incorporate nutrition education into core Incorporate nutrition education into core

curriculum as a component of a comprehensive curriculum as a component of a comprehensive SSB reduction program.SSB reduction program.

Worksite:Worksite: 11. . Encourage efforts to establish a work Encourage efforts to establish a work environment that supports good nutritionenvironment that supports good nutrition

Rationale Rationale The environment plays an The environment plays an

important role in health behaviors important role in health behaviors Employees in worksite nutrition Employees in worksite nutrition

education programs potentially education programs potentially become role models for their own family members & become role models for their own family members & other employeesother employees

EffectivenessEffectiveness ??Potential Action StepsPotential Action Steps Support efforts to provide nutrition education at Support efforts to provide nutrition education at

workwork Encourage reduction of vending machines selling Encourage reduction of vending machines selling

SSBs, place them on first floor onlySSBs, place them on first floor only

Primary Health Care:Primary Health Care: 1. Dietary Screening and Nutrition Advice1. Dietary Screening and Nutrition Advice

RationaleRationale Health care providers have contact with nearly all Health care providers have contact with nearly all

children and youth in the United States; visits provide children and youth in the United States; visits provide opportunities for educating & motivating regarding opportunities for educating & motivating regarding behavior change.behavior change.

EffectivenessEffectiveness Providers use of AAP’s 5-2-1-0 program Providers use of AAP’s 5-2-1-0 program

increases nutrition counselingincreases nutrition counselingregarding SSB consumption (Maine Youth regarding SSB consumption (Maine Youth Overweight Collaborative, 2006)Overweight Collaborative, 2006)

Potential Action StepsPotential Action Steps Expand use of screening guides such as 5-2-1-0 to Expand use of screening guides such as 5-2-1-0 to

facilitate physician screening and counselingfacilitate physician screening and counseling Advocate with insurance providers to support Advocate with insurance providers to support

reimbursement for nutrition screening & counselingreimbursement for nutrition screening & counseling

“To obtain more evidence-based practice we need more practice-based evidence”

Green L, Ottoson JM. In Hiss et al, From Clinical Trials to Community: the Science of Translating Diabetes and Obesity Research, NIH, 2004.

Monitoring & Evaluation of SSB Reduction

Activities

Monitoring & EvaluationMonitoring & EvaluationCDC – SSB Consumption MeasuresCDC – SSB Consumption Measures CSFII/NHANESCSFII/NHANES

– 24 hour dietary recall24 hour dietary recall– FFQ, “How often do you drink other fruit drinks FFQ, “How often do you drink other fruit drinks

(such as cranberry cocktail, Hi-C, lemonade, or (such as cranberry cocktail, Hi-C, lemonade, or Kool-Aid, diet or regular)? and “How often were Kool-Aid, diet or regular)? and “How often were your fruit drinks diet or sugar-free drinks? “your fruit drinks diet or sugar-free drinks? “

Youth Risk Behavior Survey (YRBS)Youth Risk Behavior Survey (YRBS)– Biennially, question added 2001Biennially, question added 2001– During the past 7 days, how many times per day During the past 7 days, how many times per day

did you usually drink a can, bottle, or glass of soda did you usually drink a can, bottle, or glass of soda or pop, such as Coke, Pepsi, or Sprite? (Do or pop, such as Coke, Pepsi, or Sprite? (Do notnot include diet soda or diet pop.)include diet soda or diet pop.)

Monitoring & Evaluation (2)Monitoring & Evaluation (2) YRBS (Special Survey 2010)YRBS (Special Survey 2010)

……sugar sweetened beveragessugar sweetened beverages such as lemonade, sweet such as lemonade, sweet tea, punch, Kool-Aid or fruit juices that are not 100% tea, punch, Kool-Aid or fruit juices that are not 100% fruit juice fruit juice (do not count 100% fruit juice or diet drinks(do not count 100% fruit juice or diet drinks)? )?

… … diet drinks, such as diet soda, diet pop, diet tea, or diet drinks, such as diet soda, diet pop, diet tea, or Crystal Light? Crystal Light?

… … sports or energy drinkssports or energy drinks, such as Gatorade or Powerade? , such as Gatorade or Powerade? (Do not count energy drinks such as Red Bull.) (Do not count energy drinks such as Red Bull.)

… … waterwater (include tap water, bottled water, and unflavored (include tap water, bottled water, and unflavored seltzer water)?seltzer water)?

… … caffeinated beveragescaffeinated beverages, such as coffee, tea, soda or pop, , such as coffee, tea, soda or pop, Red Bull, or Jolt? Red Bull, or Jolt?

… … vitamin watervitamin water? ?

Monitoring & Evaluation (3)Monitoring & Evaluation (3)State - SSB Consumption MeasuresState - SSB Consumption Measures Massachusettes- Healthy Choices Survey, 2005Massachusettes- Healthy Choices Survey, 2005

– Think about the past 7 days and tell us how often you Think about the past 7 days and tell us how often you drink the following itemsdrink the following itemsi.i. Soda (NOT DIET) (1 can or glass; count a 20 oz Soda (NOT DIET) (1 can or glass; count a 20 oz

bottle as two glasses):bottle as two glasses):ii.ii. Diet Soda Diet Soda iii.iii. Flavored drinks including punch, sports drinks like Flavored drinks including punch, sports drinks like

GatoradeGatorade®®, sweetened ice tea or other fruit-flavored , sweetened ice tea or other fruit-flavored drinks like Kool-Aiddrinks like Kool-Aid®® and Hawaiian Punch and Hawaiian Punch®®. . Do NOT Do NOT count 100% fruit juicecount 100% fruit juice..

iv.iv. Water (tap, spring, or sparkling) Water (tap, spring, or sparkling) v.v. Milk including white milk, LactaidMilk including white milk, Lactaid®®, chocolate milk or , chocolate milk or

other flavored milk like strawberry, vanilla or coffee. other flavored milk like strawberry, vanilla or coffee. (carton, glass or with cereal)(carton, glass or with cereal)

Monitoring and Evaluation Monitoring and Evaluation (4)(4)

CDC - Process measuresCDC - Process measures Common Community Measures for Common Community Measures for

Obesity Prevention (COCOMO)Obesity Prevention (COCOMO)– Community-based indicators to be determinedCommunity-based indicators to be determined

School Health Policies and Programs School Health Policies and Programs Study (SHPPS)Study (SHPPS)– Availability of soft drinks in schoolsAvailability of soft drinks in schools– Every 6 years, began 1994, SSB 2000Every 6 years, began 1994, SSB 2000

School Health ProfilesSchool Health Profiles– Conducted biennially to assess characteristics Conducted biennially to assess characteristics

of school health programsof school health programs

Monitoring and Monitoring and Evaluation (5)Evaluation (5)

DNPAO Legislative databaseDNPAO Legislative database– Fate of bills with “beverage”, 2001-08Fate of bills with “beverage”, 2001-08

EnactedEnacted 3737

PendingPending 2525

ChangedChanged 44

DeadDead 139139

Monitoring and Monitoring and Evaluation GapsEvaluation Gaps

Lack of standardized definition of Lack of standardized definition of SSBsSSBs

Lack of standardized indicators for Lack of standardized indicators for assessing individual SSB intakeassessing individual SSB intake

Lack of standardized methods for Lack of standardized methods for monitoring policy and environmental monitoring policy and environmental changechange

Need to report resultsNeed to report results

CDC Activities & ResourcesCDC Activities & Resources

CDC Resources & ActivitiesCDC Resources & Activities

Surveillance SystemsSurveillance Systems– NHANES, SHPPS, YRBS, Profiles, DNPAO Legislative DatabaseNHANES, SHPPS, YRBS, Profiles, DNPAO Legislative Database

Does Drinking Beverages with Added Sugars Increase Does Drinking Beverages with Added Sugars Increase the Risk of Overweight? Research to Practice Series the Risk of Overweight? Research to Practice Series No. 3 (practitioners)No. 3 (practitioners)

Rethink Your Drink (consumers)Rethink Your Drink (consumers)

DNPAO Technical Assistance ManualDNPAO Technical Assistance Manual

Special Interest Project (SIP) – UCLA, qualitative study Special Interest Project (SIP) – UCLA, qualitative study factors in the home that influence beverage factors in the home that influence beverage consumptionconsumption

CDC Guide to Reducing CDC Guide to Reducing SSB ConsumptionSSB Consumption

Consumption trendsConsumption trends Associated health outcomesAssociated health outcomes Factors associated with consumptionFactors associated with consumption Pros and cons of beverage alternativesPros and cons of beverage alternatives Key strategies (by setting)Key strategies (by setting)

– RationaleRationale– Evidence of effectivenessEvidence of effectiveness– Program examplesProgram examples– Barriers identified/Lessons learnedBarriers identified/Lessons learned– Potential action stepsPotential action steps– ResourcesResources

Monitoring & evaluation resourcesMonitoring & evaluation resources

THANKS !

Discussion: CDC GuideDiscussion: CDC Guide

Is content appropriate? Will it meet your program Will it meet your program

planning needs?planning needs? If not, what’s missing?If not, what’s missing? Are there components missing Are there components missing

that might be important to your that might be important to your key partners?key partners?

Discussion: Future Discussion: Future CollaborationCollaboration

What do you need most to ensure the What do you need most to ensure the effectiveness of your efforts to reduce SSB effectiveness of your efforts to reduce SSB consumption?consumption?

How can CDC and State Partners best How can CDC and State Partners best work together to advance work in this work together to advance work in this area?area? – Information on latest researchInformation on latest research– Facilitate information sharing on interventionsFacilitate information sharing on interventions– How is information best sharedHow is information best shared

State focal points?State focal points? Listserv?Listserv?