POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System and/or Improve the Health of all Children

Public Policies to Reduce Sugary DrinkConsumption in Childrenand AdolescentsNatalie D. Muth, MD, MPH, RDN, FAAP,a,b William H. Dietz, MD, PhD, FAAP,c Sheela N. Magge, MD, MSCE, FAAP,d

Rachel K. Johnson, PhD, MPH, RD, FAHA,e AMERICAN ACADEMY OF PEDIATRICS, SECTION ON OBESITY, COMMITTEE ONNUTRITION, AMERICAN HEART ASSOCIATION

abstractExcess consumption of added sugars, especially from sugary drinks, posesa grave health threat to children and adolescents, disproportionately affectingchildren of minority and low-income communities. Public policies, such asthose detailed in this statement, are needed to decrease child and adolescentconsumption of added sugars and improve health.

STATEMENT OF THE PROBLEM

Excess consumption of added sugars, especially from sugary drinks,contributes to the high prevalence of childhood and adolescent obesity,1–3

especially among children and adolescents who are socioeconomicallyvulnerable.4 It also increases the risk for dental decay,5 cardiovasculardisease,6 hypertension,7,8 dyslipidemia,9,10 insulin resistance,11,12 type 2diabetes mellitus,13 fatty liver disease,14 and all-cause mortality.15 The2015–2020 Dietary Guidelines for Americans recommend that addedsugars contribute less than 10% of total calories consumed, yet USchildren and adolescents report consuming 17% of their calories fromadded sugars, nearly half of which are from sugary drinks.16,17

Decreasing sugary drink consumption is of particular importancebecause sugary drinks are the leading source of added sugars in the USdiet,18 provide little to no nutritional value, are high in energy density,and do little to increase feelings of satiety.19,20 To protect child andadolescent health, broad implementation of policy strategies to reducesugary drink consumption in children and adolescents is urgentlyneeded.

DEFINITIONS

• Added sugars: sugars added to foods and beverages during processingor at the table, including, but not limited to, sucrose, glucose, high-fructose corn syrup, and processed, refined fruit juice added to

aChildren’s Primary Care Medical Group, Carlsbad, California;bDepartment of Community Health Sciences, Fielding School of PublicHealth, University of California, Los Angeles, Los Angeles, California;cSumner M. Redstone Global Center for Prevention and Wellness,Milken Institute School of Public Health, The George WashingtonUniversity, Washington, District of Columbia; dDivision of PediatricEndocrinology and Diabetes, School of Medicine, Johns HopkinsUniversity, Baltimore, Maryland; and eDepartment of Nutrition andFood Sciences, University of Vermont, Burlington, Vermont

Dr Muth conceptualized the report; and all authors wrote and revisedthis statement, are jointly responsible for its content, and approvedthe final manuscript as submitted.

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authors have filedconflict of interest statements with the American Academy ofPediatrics. Any conflicts have been resolved through a processapproved by the Board of Directors. The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication.

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers. However, policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent.

The guidance in this statement does not indicate an exclusive courseof treatment or serve as a standard of medical care. Variations, takinginto account individual circumstances, may be appropriate.

To cite: Muth ND, Dietz WH, Magge SN, et al. AAPAMERICAN ACADEMY OF PEDIATRICS, AAP SECTION ONOBESITY, AAP COMMITTEE ON NUTRITION, AAP AMERICANHEART ASSOCIATION. Public Policies to Reduce SugaryDrink Consumption in Children and Adolescents. Pediatrics.2019;143(4):e20190282

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beverages and foods asa sweetener. Added sugars donot include fructose and lactosewhen present naturally in fruits,vegetables, and unsweetened milk.

• Sugary drink, sugar-sweetenedbeverage, sugar drink: all terms thatrefer to beverages containing addedsugars. Such beverages include, butare not limited to, regular soda, fruitdrinks, sports and energy drinks,and sweetened coffees and teas. Inmost studies, diet drinks (defined as,40 kcal per 8 oz), 100% fruit juice,and flavored milks are notconsidered to be sugary drinks.

• Excise tax: tax imposed on productmanufacturers or distributors(which often is passed down toretailers and ultimately consumers)that increases prices of products atthe shelf or for distributors, incontrast to a sales tax in which thetax is added at the register.

BACKGROUND

In its scientific statement on the roleof added sugars and cardiovasculardisease risk in children, the AmericanHeart Association (AHA) concludedthat strong evidence supports theassociation of added sugars withincreased cardiovascular diseaserisk through increased caloricintake, increased adiposity, anddyslipidemia.6 The 2015 DietaryGuidelines Advisory Committee drewsimilar conclusions and advised thatpublic health strategies are needed toreduce consumption of sugary drinks,the leading source of added sugarsin the diets of US children andadolescents.21 Highlighting the globalproblem of excess sugar intake andthe international urgency to act, theEuropean Society for PaediatricGastroenterology, Hepatology andNutrition called on nationalauthorities to adopt policies aimed atreducing free sugar intake in infants,children, and adolescents.22

The World Health Organizationrecommends limiting added sugars

intake to less than 10% of totalcalories, with increased benefits ofreducing intake to less than 5% ofcalories.23 The 2015–2020 DietaryGuidelines for Americans alsorecommends that less than 10% ofcalories consumed be from addedsugars.16 The AHA recommends thatchildren 2 years and older consume#25 g (6.25 teaspoons) of addedsugars per day and no more than 8oz of sugary drinks per week.Added sugars should not be in thehabitual diet of children youngerthan 2 years.6 Despite theserecommendations, US children andadolescents report consuming 17% oftheir calories from added sugars,nearly half of which are from sugarydrinks. Those at the highest quintilereport consuming 620 kcal daily fromadded sugars, of which nearly 300kcal (equivalent to 75 g or 18.75teaspoons) are from sugary drinks.17

Many of these high consumers areadolescent boys, who report drinking,on average, 278 kcal of added sugarsper day.24

Previous American Academy ofPediatrics (AAP) publications havestressed the important role thatpediatricians play in the earlyidentification, prevention, andtreatment of obesity.25 The AAP alsorecommends that pediatric healthcare providers become more involvedin schools, advocating for healthierfoods and activities.26 In its 2017statement, “Fruit Juice in Infants,Children, and Adolescents: CurrentRecommendations,” the AAP advisedpediatricians to support policies thatseek to limit the consumption of fruitjuice (ie, no juice in children youngerthan 1 year, no more than 4 oz perday in children ages 1–3 years, nomore than 4–6 oz per day inchildren ages 4–6 years, and nomore than 8 oz per day in childrenages 7–18 years), including childrenparticipating in the SpecialSupplemental Nutrition Program forWomen, Infants, and Children(WIC).27 In its 2011 statement on

sports and energy drinks, the AAPrecommended that children andadolescents avoid all energy drinksand the routine consumption ofcarbohydrate-containing sportsdrinks and instead drink water.28

On the basis of lessons learned fromtobacco-control efforts (1 of thegreatest public health successesof the United States) the AAP andAHA offer additional policyrecommendations targeted at federal,state, and local policy makers toimprove child nutrition throughreduced sugary drink intake. Thesepolicies are best implemented inconjunction with local pediatriciansupport to respond to the urgentneed to reduce added sugarsconsumption in children andadolescents.

PUBLIC POLICY RECOMMENDATIONS

1. Local, state, and/or nationalpolicies intended to reduceconsumption of added sugars shouldinclude the consideration ofapproaches that increase theprice of sugary drinks, such as anexcise tax. Such taxes should beaccompanied by education ofall stakeholders on the rationaleand benefits of the tax beforeimplementation. Tax revenues shouldbe allocated, at least in part, toreducing health and socioeconomicdisparities.

Price increases are associated witha decrease in consumption. Forexample, as tobacco prices increased,cigarette consumption droppedprecipitously, particularly amongyouth and people of lowersocioeconomic status.29 Strongevidence indicates that alcohol excisetaxes reduce excessive alcoholconsumption and its associatedharmful consequences, such as motorvehicle collisions.30 In the case ofsugary drinks, a systematic reviewrevealed that each 10% increase inprice, such as a tax, reduced sugarydrink consumption by 7%.31 TheWorld Health Organization suggests

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that a higher tax of 20% would mostlikely have the greatest effect onreducing consumption.32 TheChildhood Obesity Intervention Cost-Effectiveness Study (CHOICES),a modeling study aimed at identifyingthe most cost-effective interventionsto reduce childhood obesity, foundimplementation of a sugary drink taxto be the most cost-effective strategyto address childhood obesity, leadingto prevention of 575 000 cases ofchildhood obesity and a health caresavings of $30.78 per dollar spentover 10 years.33 Such taxes are mosteffective when accompanied bya broad education campaign to helpstakeholders understand the risks ofsugary drink consumption and therationale and benefits of the tax.34

Several countries have implementedthese types of taxes. In 2014, Chileraised the tax on drinks containingmore than 6.25 g of added sugars per100 mL from 13% to 18% andlowered the tax on drinks with under6.25 g of added sugars per 100 mLfrom 13% to 10%. Researchers foundthat sugary drink purchasesdecreased 21% in the year after thetax took effect.35 The most rigorouslyevaluated sugary drink tax is Mexico’s2014 implementation of a nationwide10% excise tax (1 peso per liter) onsugary drinks. The successful passageand implementation of the taxresulted from a broad educationcampaign organized by taxproponents that included coalitionbuilding, lobbying, media advocacy,public demonstrations, multipleforums, drafting of a legislativeproposal, and public opinionpolling.36 As a result of the tax, theaverage volume of taxed beveragespurchased was 5.5% lower in 2014than expected without the tax, witha 9% decrease in sales to lower-income households.37 A follow-upstudy of the second year of the tax(2015) revealed that consumptiondecreased 9.7% from baseline. Thus,over the 2 years after the tax wasimplemented, the net decrease in

sugary drinks was 7.6%. Purchases ofuntaxed beverages, such as water,increased 2.1%.38 This tax alone isprojected to prevent nearly 200 000cases of obesity and save $980million in direct health care costsfrom 2013 to 2022, with the majorityof benefits afforded to young adults.39

Berkeley, California, was the first UScity to levy a relatively large tax($0.01 per oz) on sugary drinks,effective March 2015. A study of theimpact of the tax (comparing pre- and1-year posttax beverage prices at 26Berkeley stores; point-of-sale scannerdata on 15.5 million checkouts forbeverage prices, sales, and storerevenue for 2 supermarket chains in3 Berkeley and 6 nearby control non-Berkeley large supermarkets; anda representative telephone survey of957 adult Berkeley residents)revealed that approximately 67% ofthe tax was passed on to consumers.Sales of sugary drinks fell 9.6%,whereas sales of untaxed beverages,such as water and milk, increased3.5%. There was no increase ingrocery bills for consumers or loss ofrevenue or decrease in beverage salesfor stores.40 Other studies of theBerkeley tax have found similarresults,41,42 although 1 study43 foundthat the tax had minimal impact. Theauthors of that study cited a low pass-through rate and, thus, limited sugarydrink price increase to the consumer.However, results may have beenskewed because in the evaluation,national chains that were coveredby the law in the first year werecombined with small stores that wereonly covered by the law in thesecond year.

Other US locales, including SanFrancisco, Oakland, and Albany,California; Philadelphia,Pennsylvania; Boulder, Colorado;and Seattle, Washington, haveimplemented an excise tax onsugary drinks. Cook County, Illinois(Chicago), which did not have a highdegree of buy-in from stakeholdersbefore implementation and was

associated with substantial industryresistance, briefly implementeda sales tax on sugary drinks butthen repealed it.44 Some states havepassed preemption laws thatprohibit local municipalities fromimplementing a tax on sugary drinks.In June 2018, California lawmakerspassed a law prohibiting any newlocal sugary drink taxes until 2031 inresponse to threats from theAmerican Beverage Association,which funded a likely-to-pass ballotmeasure that would require a two-thirds majority of voters to approveany local tax increase. In exchange,the American Beverage Associationdropped the ballot measure. Theselaws stifle local innovation to meetthe health and fiscal needs ofconstituents and are counter toa 2011 report from the Institute ofMedicine (now the National Academyof Medicine), in which federal andstate legislators were urged to “avoidframing preemptive legislation ina way that hinders public action.”45

Although people of lowersocioeconomic status bear a greaterburden from taxation, they alsodisproportionately benefit from thehealth and economic benefits fromprevention of cardiovascular diseaseand type 2 diabetes mellitus.39

Moreover, if the tax revenue isallocated to decrease healthdisparities or provide other servicesthat promote health in these specificgroups, the tax ultimately may beprogressive.46,47 For example, thePhiladelphia tax has been used tofund prekindergarten programs thatare of direct benefit to underservedcommunities.

Given the success of tobacco andalcohol taxes in reducing adolescentuse and consumption of theseproducts, policy makers shouldconsider enacting policies that raisethe price of sugary drinks. A portionof tax revenues could be used tosubsidize healthier options, such aswater, milk, fruits, and vegetables,

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and/or child health or obesity anddiabetes prevention programs.

2. The federal and stategovernments should support effortsto decrease sugary drink marketingto children and adolescents.

Similar to tobacco companies, sugarydrink manufacturers aim to appeal tochildren and adolescents byassociating their product withcelebrity, glamour, and coolness.Despite the existence of the Children’sFood and Beverage AdvertisingInitiative, an industry-initiated, self-regulatory body designed to limitmarketing of unhealthful food andbeverage products to childrenyounger than 12 years, children andadolescents are frequently exposed tosugary drink advertisements. In 2009,carbonated beverage companiesreported $395 million in youth-directed expenditures, approximately97% of which were directed atteenagers.48 According to recentNielsen data reported by theUniversity of Connecticut RuddCenter, children’s exposure toadvertisements for carbonatedbeverages increased 19% and theirexposure to advertisements for juice,fruit drinks, and sports drinksincreased 38% from 2015 to 2016.Overall, advertisements for sugarydrinks have increased substantiallysince 2007.49 Beverages are moreheavily promoted to adolescents thanto younger children,48 who may onlysee 1 beverage advertisement per dayon children’s programs.50 An onlinesurvey of US adolescents ages 12 to17 years (n = 847) revealed thatalmost half of the adolescentsreported daily sugary drinkadvertising exposure.51 Amongsurvey respondents, 14- to 15-year-old, African American maleadolescents whose parents had a highschool education or less (factorsassociated with increased sugarydrink consumption52) reported thehighest exposure to advertising ofsoda, fruit drinks, sports drinks, andenergy drinks.51 Because children

tend to consume the beveragespromoted on television and becauseAfrican American children areexposed to the most sugary drinkadvertisements, the disparity insugary drink advertising exposuremay contribute to thedisproportionate rates of obesityamong African American children.

Stronger measures are needed tocurtail advertising of sugary drinks tochildren and adolescents ontelevision, on the Internet, and inplaces frequented by children, such asmovie theaters, concerts, andsporting events. Although companiesare protected by commercial freespeech rights and may not bemandated to stop advertising tochildren and adolescents, othermethods to reduce advertising ofunhealthful food and beverages tochildren and adolescents could beused. For example, businesses arepermitted to deduct costs ofadvertising as a business expense.Modeling by the CHOICES studysuggests that eliminating theadvertising subsidy for nutritionallypoor foods and beverages marketedto children would preventapproximately 129 000 cases ofobesity over a decade at a cost $0.66for each unit of BMI reduced. Theadditional benefit of this approach isthat it would generate approximately$80 million annually in tax revenue.33

The US Congress should consider thisand other allowable measures toreduce advertising of sugary drinks tochildren and adolescents.

State governments should implementthe US Department of Agriculture’s(USDA) local school wellness policyfinal rule under the Healthy, Hunger-Free Kids Act of 2010, which requiresthat only foods and beveragesmeeting the Smart Snacks standardsmay be marketed on school campusesduring the school day.53 Stategovernments should also consideradditional strategies to reduce sugarydrink marketing and advertising tochildren and adolescents through

measures such as prohibitions oncoupons, sales, and advertising in andaround schools and on school busesas well as sugary drink–brandedsponsorship of youth sporting events.

3. Federal nutrition assistanceprograms should aim to ensureaccess to healthful food andbeverages and discourageconsumption of sugary drinks.

Several federal nutrition programsdirect taxpayer dollars towardreducing food insecurity andsupporting healthful nutrition forchildren and families of low income.

WIC

WIC provided nutritious foods tonearly 1.9 million infants and 4million children ages 1 to 5 years infiscal year 2016. WIC providesa supplemental package of healthfulfoods and beverages and offersa robust nutrition education program.Although 100% juice is allowed,sugary drinks are not included in theWIC package.

Child and Adult Food Care Program

More than 3 million children areserved by the Child and Adult CareFood Program (CACFP) (a programadministered by the USDA), whichprovides cash assistance to states toprovide healthful food to children andadults in child and adult careinstitutions. Sugary drinks arenoncreditable items in the CACFP (ie,they may be served but do not counttoward meeting the meal patternrequirements for a meal to bereimbursed). Flavored milks are notcreditable for children ages 2 to5 years but are creditable for childrenand adults older than 6 years if theycontain no more than 22 g of totalsugars per 8 oz. The CACFP bestpractices advise early care andeducation centers to avoid servingnoncreditable sugary drinks in theirfacilities.54 However, few statescurrently have any provisionsprohibiting access to sugary drinks inthese settings. Because most early

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care and education centers areregulated at the state, rather thanfederal, level, states should adoptpolicies that restrict early care andeducation centers from servingchildren sugary drinks.

School Breakfast Program, SchoolLunch Program, and Competitive Foods

The Healthy, Hunger-Free Kids Act of2010 required the USDA to establishnational nutrition standards for allfoods sold in schools at any time,including foods sold for schoolbreakfast and school lunch andcompetitive foods sold outside mealprograms (Smart Snacks standards).The adopted standards do not allowsugary drinks in elementary ormiddle school and only allow drinksother than 100% fruit juice, milk, orapproved milk alternatives if theycontain less than 40 kcal per 8 oz orless than 60 kcal per 12 oz for highschools. A 2018 final rule allowsstates flexibility to include flavoredlow-fat milk, in addition to flavorednonfat milk, as long as school mealsstay within calorie requirements.55

The CHOICES modeling studypredicts that nutrition standards forall school meals will likely prevent 1.8million cases of childhood obesityfrom 2015 to 2025 and save $0.42per dollar spent and that includingnutrition standards for allcompetitive foods and beverages willprevent 345 000 cases of childhoodobesity and save $4.56 per dollarspent.33 Additional evidence indicatesthat adolescents drink fewer sugarydrinks when standards such as theseare implemented.56–59 Ultimately, theHealthy, Hunger-Free Kids Act andSmart Snacks standards improvedchildren’s nutrition and reducedintake of added sugars,60–62 althoughadditional technical assistance andsupports are needed to increasecompliance.61,63,64 These policiesshould be implemented, enforced,and enhanced to further promotea healthy school environment. Thepolicies also should be accompaniedby a robust nutrition education

program to help children andadolescents understand how to makehealthy food and beverage choices,including information on how toidentify and respond to marketingmessages and how to read nutritionlabels.

Supplemental Nutrition AssistanceProgram

The Supplemental NutritionAssistance Program (SNAP), a vitalsafety net program that provides foodfor 45 million families, including 23million children, is the nation’slargest child nutrition program,serving approximately 1 in 4 USchildren.65 Although SNAP has provensuccessful at addressingundernutrition and food insecurity, itis the only government feedingprogram that does not have nutritionstandards to address diet quality. Inthe 2015 Dietary Guidelines AdvisoryCommittee report, it was advised thatchanges be made to align WIC andSNAP with the Dietary Guidelines forAmericans, including encouraging thepurchase of healthful foods anddiscouraging the purchase andconsumption of sugary drinks.21

Additionally, the Dietary GuidelinesAdvisory Committee suggested thatefforts are necessary to reduce accessto sugary drinks in communitysettings and that they should beseamlessly integrated with foodassistance programs, includingSNAP.21 Each day, SNAP dollars payfor 20 million servings of sugarydrinks at an annual cost of $4billion.66 If sugary drinks were notincluded as a SNAP benefit, estimatessuggest that 510 000 type 2 diabetesmellitus person-years and 52 000deaths could be averted, witha savings of $2900 per quality-adjusted life-years saved.67 Quality-adjusted life-years is an economicmeasure of the state of health ofa person that combines quality of lifeand longevity.

The public and SNAP participantssupport both improved access to

healthful foods within SNAP andremoval of SNAP benefits for sugarydrinks.68,69 States cannot makechanges to SNAP benefits withouta waiver from the USDA. Nonetheless,the USDA has repeatedly rejectedstates’ requests for waivers and pilotstudies that would eliminate sugarydrinks from SNAP. The USDA hascited concerns related to retailerimplementation as well as the needfor a robust evaluation framework.Moreover, the USDA and antihungerorganizations have raised manyconcerns about the consequences ofsuch a restriction, leading to a clearneed to evaluate such a policy andgain public support before itsimplementation.70 There is concernthat a restriction might increasestigma and embarrassment andsubsequently deter SNAPparticipation if a SNAP participantattempts to purchase a sugary drinkwith SNAP benefits and is denied atthe counter. A robust informationcampaign detailing the benefits ofchange might counter, but would noteliminate, this risk, and policiesshould be sensitive to this issue. Somehave also questioned the restrictionof sugary drinks from SNAP whereasother highly processed, nonnutritiousfoods containing substantial amountsof added sugars (eg, snack cakes,cookies, etc) are still allowed. There isalso concern that any change to SNAPmay prompt cuts to the food benefitsthat participants receive.71 Becausethe current SNAP benefit amounts toan average of $1.40 per person permeal, it is imperative that SNAPbenefits and eligibility not onlyremain intact but also increase toprovide families with the resourcesthey need to obtain an adequate,healthful diet throughout the month.

The Healthy Incentives Pilot offersa model to evaluate the effects ofmaking a change to SNAP. In 2008,Congress directed $20 million to funda pilot project to subsidize fruit andvegetable purchases within SNAP.The Healthy Incentives Pilot

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demonstrated that providing a 30-cent incentive for every SNAP dollarspent on fruits and vegetablesincreased purchases of fruits andvegetables by 26%.72 A randomizedcontrolled trial conducted inMinnesota revealed that a foodbenefit program that pairedincentives to eat healthful foods, suchas fruits and vegetables, withrestrictions on sweet baked goods,candies, and sugary drinks decreasedcaloric intake and improved thenutritional quality of participants’diets, compared with no change,incentive only, or restriction only.73

A survey of SNAP participants andSNAP-eligible nonparticipantsrevealed support for policies thatprovided an incentive to purchasehealthful foods and imposedrestrictions on sugary drinks.74

Congress could authorize the USDA toconduct a study to evaluate a fruitand vegetable incentive combinedwith restriction of sugary drinks.Such a study may help clarify theeffects on consumer purchasing andSNAP participant perspectives,including real or perceived stigma,dietary quality, and retailerimplementation. In addition, SNAPEducation, the nutrition educationcomponent of the program, providesa mechanism to develop and testpolicy, system, and environmentalchanges to promote fruit andvegetable consumption and reducesugary drink intake.75 SNAPEducation should be expanded andfurther developed so as to furtheremphasize the health benefits offruits and vegetables and thehealth risks of sugary drinks andadded sugars. Retailer incentivesand new retail stocking standardscould be used to reduce purchaseof sugary drinks and increasepurchase of healthier foods. It iscritical that any change to SNAPpreserves and enhances access tohealthful foods and the integrity ofthis vital nutrition program with nodecrease in the benefits toparticipants.

4. Children, adolescents, and theirfamilies should have ready access tocredible nutrition information,including on nutrition labels,restaurant menus, andadvertisements.

Whether nutrition labels helpimprove health is unclear.76 However,just as consumers are advised of thehealth risks of nicotine andcarcinogens when purchasing tobaccoproducts, they also should be advisedof nutritional risks when makingpurchases of sugary drinks, givingthem the opportunity to use thisinformation to make healthierchoices. Encouraging policy changesinclude implementation of theregulations that require added sugarscontent to be included on thenutrition facts panel and onrestaurant menus. Consumerssupport such measures. In 1 survey,84% of adults believed “thegovernment should require nutritioninformation labels on all packagedfood sold in grocery stores,” and 64%wanted similar requirements forrestaurants.77 Consumer educationon how to read and use nutritionlabels may help increase labeleffectiveness in changing behavior.For example, a study of 34adolescents revealed that studentssignificantly increased their ability toread and understand a nutrition labelafter a brief school-based educationalintervention.78 Additionally,a systematic review of 16 studiesfound that increased nutritionknowledge and education wasassociated with nutrition label use incollege students.79

Front-of-package labels, includingwarning labels of the health harms ofconsumption of added sugars, couldserve to further empower families tomake healthier choices. For example,a randomized trial of 2000adolescents revealed that those whowere exposed to a health warninglabel chose fewer sugary drinks andbelieved that sugary drinks were lesslikely to help them lead a healthy

life.80 When parents were exposed toa warning label, they chosesignificantly fewer sugary drinks,believed that sugary drinks were lesshealthful for their children, and wereless likely to intend to purchasesugary drinks.81 The constitutionalityof warning labels has been challengedby industry.82 The controversy wasprompted by a 2015 San Franciscoordinance that requiredadvertisements for sugary drinks toinclude a disclaimer that says“WARNING: Drinking beverages withadded sugar(s) contributes to obesity,type 2 diabetes, and tooth decay.” In2019, the Ninth Circuit Court ofAppeals blocked the law, ruling that it“unduly burdens and chills protectedcommercial speech” and is not purelyfactual because the US Food and DrugAdministration has stated that addedsugars are “generally recognized assafe” and “can be part of a healthydietary pattern when not consumedin excess amounts.”83

5. Policies that make healthybeverages the default should bewidely adopted and followed.

Policies and incentives shouldsupport decreased consumption ofsugary drinks through environmentalchanges, such as promoting healthieroptions (like water and milk) anddecreasing access to and portion sizesof sugary drinks in all locationswhere children and adolescents arepresent. For example, currentstandard beverage policy for federalagencies requires that 50% ofbeverages contain #40 kcal per8 oz except for 100% juice orunsweetened fat-free or 1% milk.84

For all vending machines contractedby New York City agencies, policyprohibits advertisements, limits high-calorie beverages to 12 oz anda maximum of 2 slots in the vendingmachine, requires the provision ofwater in 2 slots at eye level, andrequires that all other beveragesother than milk contain #25 kcal per8 oz.85 Several cities, states, and stateparks have implemented food service

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guidelines, including the provision ofhealthful beverages.86–88 In August2018, California became the first stateto pass a law requiring restaurants toserve water or milk as the defaultbeverage in kids’ meals. Hawaii,Vermont, Connecticut, Rhode Island,and New York City are consideringsimilar bills, and several cities inCalifornia; Baltimore, Maryland;Louisville, Kentucky; and Lafayette,Colorado have already passed“healthy-by-default” cityordinances.89 Some restaurants havevoluntarily changed the defaultbeverage choice on the children’smenu from soda and other sugarydrinks to water or milk, althoughmore than 75% of the 50 largestchain restaurants have not.89 A fewrestaurants have gone further andeliminated sugary drinks fromchildren’s menus altogether.90

Although data on the effects of thesetypes of changes are limited, someevidence suggests when the healthierchoice is the easier or default choice,people are more likely to make it.91–93

6. Hospitals should serve as a modeland implement policies to limit ordisincentivize purchase of sugarydrinks.

One of the less recognizedcontributors to the reduction incigarette smoking is the role thatphysicians and hospitals played inchanging social norms regardingtobacco use. Before the 1950s,physicians and their choice of cigarettebrands featured prominently incigarette advertising.94 In the 1960s,hospital grand rounds were conductedin smoke-filled rooms, and doctorswho smoked were less likely tocounsel regarding the adverse healtheffects of smoking. However, asawareness of the medicalconsequences of tobacco use grew,physicians stopped smoking, andhospitals eliminated cigarette vendingmachines and the sale of cigarettes inhospital gift shops.94–96 Althoughtobacco use remains a pressing threatto public health, the ongoing obesity

epidemic and high consumption ofadded sugars has led to epidemics oftype 2 diabetes mellitus and metabolicdisease that require increased actionby physicians and other health careproviders, hospitals, and many othermembers of civil society.6,97,98

As with the ban on tobacco,leadership by hospitals and healthplans to eliminate the sale of sugarydrinks can improve the health of theiremployees, increase public awarenessabout the contribution of sugarydrinks to obesity, and thereby changesocial norms regarding sugary drinks.For example, the Boston Public HealthCommission engaged with 10 medicalcenters in Boston to reduce sugarydrink consumption using a variety ofstrategies. Massachusetts GeneralHospital labeled drinks with red,yellow, or green stickers to indicatetheir calorie content and made thehigh-calorie drinks less accessible.Over 2 years, consumption ofhealthier products increased,consumption of high-caloriebeverages decreased, and there wasa modest increase in revenue frombeverage sales.99 A second hospitalfound that increased prices of high-calorie beverages reduced theirsales.100 Many hospitals have stoppedselling sugary drinks entirely. In2010, the Cleveland Clinic eliminatedthe sale of sugary drinks, extendingprevious efforts to improve communityhealth through hospital practices bybanning smoking on campus andeliminating the use of trans fats.101 In2011, Nationwide Children’s Hospitaleliminated all sugary drinks in all foodestablishments within the hospital,with no loss of revenue.102 In 2018,Geisinger eliminated sales of sugarydrinks from all campuses.103 More than30 health systems comprising morethan 250 hospitals are participating inthe Healthier Hospital Initiative, whichincludes a pledge to increase healthfulbeverages to 80% of total beveragepurchases in patient care, retail,vending, and catering.104 In 2017, theAmerican Medical Association passed

a resolution that “encourages hospitalsand medical facilities to offer healthierbeverages, such as water, unflavoredmilk, coffee, and unsweetened tea, forpurchase in place of SSBs [sugar-sweetened beverages].”97 A usefulguide for the development of healthfulbeverage programs has been publishedby the Public Health Law Center andthe Centers for Disease Control andPrevention.105,106

Decisions to reduce promotion andsale of sugary drinks in hospitals mayappear to be a distraction fromhospitals’ core efforts to providemedical care or appear to beineffective given that most sugarydrink consumption does not occur inhospitals. The same arguments couldhave been made about hospitals’efforts to reduce the promotion andsale of tobacco. A well-publicizedeffort to reduce sugary drinkconsumption among hospitalpatients, visitors, and staff could helpbuild public awareness of the linksbetween sugary drink consumption,obesity, and diabetes. These effortscould also signal to employers andleaders in other settings that reducingsugary drink sales and promotion inworksites and public spaces is animportant and feasible approach toimproving population health.

CONCLUSIONS

Consumption of added sugars,particularly those in sugary drinks,pose a significant health risk tochildren and adolescents.Pediatricians are encouraged toroutinely counsel children andfamilies to decrease sugary drinkconsumption and increase waterconsumption. Pediatricians can alsoadvocate for policy change throughschool boards, school health councils,hospital and medical group boardsand committees, outreach to electedrepresentatives, and public commentopportunities. Policy targets, such asthose discussed in this report andsummarized below, are needed to

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reduce sugary drink consumption inchildren and adolescents andsubsequently improve child health.

1. Local, state, and/or nationalpolicies to reduce added sugarsconsumption should includepolicies that raise the price ofsugary drinks, such as an excisetax. Such taxes should beaccompanied by an educationcampaign on the risks of sugarydrinks and on the rationale andbenefits of the tax and should besupported by stakeholders. Taxrevenues should be allocated, atleast in part, to reducing healthand socioeconomic disparities.Metrics should be established toevaluate the impact of such a tax.

2. The federal and state governmentsshould support efforts to decreasesugary drink marketing to childrenand adolescents.

3. Federal nutrition assistanceprograms should ensure access tohealthful foods and beverages anddiscourage consumption of sugarydrinks.

4. Children, adolescents, and theirfamilies should have ready accessto credible nutrition information,including on the nutrition factspanel, restaurant menus, andadvertisements.

5. Policies that make healthfulbeverages the default choiceshould be widely adopted andfollowed.

6. Hospitals should serve as a modeland implement policies to limit ordisincentivize the purchase ofsugary drinks.

Although the strength and availabilityof evidence supporting the policyrecommendations addressed in thisreport vary and although there may besignificant barriers or considerations inimplementation of some or all of theserecommendations, pediatricians maytailor their advocacy efforts toapproaches that are most likely to leadto decreased access to and consumptionof sugary drinks in the children andfamilies they serve, whether on a local,state, or federal level.

LEAD AUTHORS

Natalie D. Muth, MD, MPH, RDN, FAAPWilliam H. Dietz, MD, PhD, FAAPSheela N. Magge, MD, MSCE, FAAPRachel K. Johnson, PhD, MPH, RD, FAHA

AAP SECTION ON OBESITY EXECUTIVECOMMITTEE, 2017–2018

Christopher F. Bolling, MD, FAAP,ChairpersonSarah C. Armstrong, MD, FAAPMatthew Allen Haemer, MD, MPH, FAAPNatalie D. Muth, MD, MPH, RDN, FAAPJohn Conrad Rausch, MD, MPH, FAAPVictoria Weeks Rogers, MD, FAAP

LIAISONS

Marc Michalsky, MD, FACS, FAAP – AmericanAcademy of Pediatrics Section on Surgery

CONSULTANT

Stephanie Walsh, MD, FAAP

STAFF

Mala Thapar, MPH

AAP COMMITTEE ON NUTRITION, 2017–2018

Steven A. Abrams, MD, FAAP, Chairperson

Jae Hong Kim, MD, PhD, FAAPSarah Jane Schwarzenberg, MD, FAAPGeorge Joseph Fuchs III, MD, FAAPSheela N. Magge, MD, MSCE, FAAPC. Wesley Lindsey, MD, FAAPEllen S. Rome, MD, MPH, FAAP

LIAISONS

Cria G. Perrine, PhD – Centers for DiseaseControl and PreventionAndrea Lotze, MD, FAAP – US Food and DrugAdministrationJanet M. de Jesus, MS, RD – NationalInstitutes of HealthValery Soto, MS, RD, LD – US Department ofAgriculture

STAFF

Debra L. Burrowes, MHATamar Haro

AHA STAFF

Laurie Whitsel, PhD, FAHA

ABBREVIATIONS

AAP: American Academy ofPediatrics

AHA: American Heart AssociationCACFP: Child and Adult Care Food

ProgramCHOICES: Childhood Obesity

Intervention Cost-Effectiveness Study

SNAP: Supplemental NutritionAssistance Program

USDA: US Department ofAgriculture

WIC: Special SupplementalNutrition Program forWomen, Infants, andChildren

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before

that time.

DOI: https://doi.org/10.1542/peds.2019-0282

Address correspondence to Natalie D. Muth, MD, MPH, RDN, FAAP. E-mail: nmuth@rchsd.org

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2019 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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DOI: 10.1542/peds.2019-0282 originally published online March 25, 2019; 2019;143;Pediatrics 

COMMITTEE ON NUTRITION and AMERICAN HEART ASSOCIATIONAMERICAN ACADEMY OF PEDIATRICS, SECTION ON OBESITY, Natalie D. Muth, William H. Dietz, Sheela N. Magge, Rachel K. Johnson,

AdolescentsPublic Policies to Reduce Sugary Drink Consumption in Children and

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DOI: 10.1542/peds.2019-0282 originally published online March 25, 2019; 2019;143;Pediatrics 

COMMITTEE ON NUTRITION and AMERICAN HEART ASSOCIATIONAMERICAN ACADEMY OF PEDIATRICS, SECTION ON OBESITY, Natalie D. Muth, William H. Dietz, Sheela N. Magge, Rachel K. Johnson,

AdolescentsPublic Policies to Reduce Sugary Drink Consumption in Children and

http://pediatrics.aappublications.org/content/143/4/e20190282located on the World Wide Web at:

The online version of this article, along with updated information and services, is

by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397. the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2019has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

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