i Making the Connection: Physical Activity and Positive Youth Development

Sugary Drinks in Communities of Color:

Recent Research and Policy Options to Reduce

Consumption March 2015

Leadership for Healthy Communities is a national program of the Robert Wood Johnson Foundation.

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ii Making the Connection: Physical Activity and Positive Youth Development

Copyright 2015 Robert Wood Johnson Foundation.

This brief was produced by the Center for Global Policy Solutions with direction from the Robert Wood Johnson Foundation (RWJF) for the RWJF Leadership for Healthy Communities program.

twitter.com/LHCommunities

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Leadership for Healthy Communities is a national program of the Robert Wood Johnson Foundation designed to support local and state government leaders nationwide in their efforts to reduce childhood obesity through public policies that promote active living, healthy eating and access to healthy foods. For more information, visit www.leadershipforhealthycommunities.org.

1 Sugary Drinks in Communities of Color

Introduction

Sugary drinks are routinely available in the United States. In recent years, however, such beverages—sodas, sports drinks, energy drinks, fruit drinks other than 100 percent fruit juice, and sugar-sweetened teas and coffees—have come under increased public scrutiny. Research provides strong evidence of a link between the consumption of sugary drinks and weight gain, metabolic syndrome and type 2 diabetes.1 Despite decreasing consumption of some of these beverages over the past decade, Americans consume on average more than 150 calories from sugary drinks each day, the equivalent of one 12-ounce can of soda.2 In communities of color, where regular consumption of these drinks is more likely, the health impact is particularly acute and obesity-related chronic diseases are more prevalent.

This policy brief investigates sugary drink consumption in communities of color, focusing on the public health impact and marketing of such products, and policy options to facilitate healthy beverage consumption. It discusses how decision makers can work to prevent childhood obesity and related illnesses by advancing policies to reduce the marketing and appeal of sugary drinks—and increase the availability of healthy alternatives—in communities of color.

FACTS AT A GLANCE

Consumption of sugary drinks is associated with poor health outcomes, including excessive weight gain, childhood and adult obesity, type 2 diabetes, and tooth decay.

Children who drink a 12-ounce soda every day are 60 percent more likely to become obese than those who do not.

People of color are more likely to have limited access to healthy beverages, more inclined to consume sugary beverages, and more affected by preventable chronic diseases.

Food and beverage companies disproportionately target marketing efforts promoting sugary drinks toward people of color.

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Consumption of Sugary Beverages in Communities of ColorFor children of color, high daily consumption of sugary beverages early in life is a significant risk factor for childhood obesity.3 African-American and Mexican-American children typically consume a higher proportion of daily calories from these drinks than do white children.4 (See Figure 1.) For teens, sugary drink consumption exceeds current USDA recommendations, which state that less than 10 percent of calories should be from “empty” sources, defined as calories from sugar or fat.5

In addition, about half of U.S. adults consume sugary drinks on any given day, with one-quarter consuming at least 200 calories a day from these beverages.6 These consumption levels exceed the American Heart Association’s recommendation that adults consume no more than 450 calories from these drinks per week.7 Excessive consumption of sugary beverages is associated with several socioeconomic factors, including race, income, and educational attainment. African-American and Latino adults consume more daily calories than white adults from such drinks, especially sugar-loaded fruit-flavored drinks.8 Adults without a high school diploma are also more likely to consume these drinks than those who have graduated.9

Furthermore, a disproportionate number of African-Americans and Latinos live in food deserts with limited access to healthy, affordable food and beverages.11 Food deserts typically have a plethora of corner stores, fast-food restaurants, and bodegas that sell unhealthy beverages.12 Concurrently, full-service supermarkets, which are more likely to offer a variety of healthy products at lower prices, are often missing or insufficient in communities of color.13 In fact, African-American neighborhoods only have about half the number of chain supermarkets as predominantly white neighborhoods.14 Children living in food deserts frequently purchase inexpensive but unhealthy beverages in corner stores that are often located near schools. This increases caloric intake among children in urban areas by about 350 additional calories a day.15

Figure 1. Percentage of daily caloric intake from sugary drinks among children, 2009-201010

DEFINITION

The Departments of Agriculture, Treasury, and Health and Human Services define a food desert as “a census tract with a substantial share of residents who live in low-income areas that have low levels of access to a grocery store or healthy, affordable food retail outlet.”16

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Contributions of Sugary Drinks to Health Risks in Communities of Color

Consumption of sugary drinks is associated with a number of health problems in children and adults, including obesity, type 2 diabetes, and tooth decay. Based on 2010-2012 survey data, Latino and African-American adults are nearly twice as likely to develop type 2 diabetes as white adults.17 Specific research on African-American women found that regular consumption of sugary beverages increases the risk of type 2 diabetes by 24 to 31 percent.18

Sugary drink consumption can also lead to tooth decay, the most common chronic disease that affects children. This erosion of tooth enamel can be extremely painful and can cost, on average, $700 in hospital-based emergency department charges per child.19 Moreover, tooth decay in children can have serious consequences, including lost school hours, difficulty learning, pain and suffering, and problems with eating and speaking.20 African-American and Latino children and adults are more likely to have tooth decay than whites of the same socioeconomic status are, and also are more likely to have it go untreated.21

Obesity rates are significantly higher among minority children and adults than in the general population. According to the most recent data from the National Health and Nutrition Examination Survey, African-American women have the greatest risk of becoming obese. About 36 percent of African-American girls ages 2 to 19 and 82 percent of adult African-American women are overweight or obese.22 Sugary drink consumption only increases this risk.23 People who regularly consume such beverages often feel less full than if they had eaten solid food with the same number of calories, and this may lead them to consume more daily calories than needed.24

Figure 2. Prevalence of overweight and obesity among children and adults by race/ethnicity, 2011-201225

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4 Sugary Drinks in Communities of Color

Youth of color are more likely to be overweight or obese than are white youth, and are at greater risk of developing preventable chronic diseases as adults.26 Figure 2 shows that a larger percentage of African-American and Latino children ages 2 to 19 are overweight or obese than white children. Also, recent studies of American Indian and Alaska Native children ages 2 to 4 found that 21 percent are obese and 41 percent are overweight or obese compared to 12 percent and 28 percent respectively for white children of the same age.27 Although adolescents of color are at higher risk, childhood obesity is prevalent across all races and is exacerbated by sugary drink consumption. In fact, children who drink a 12-ounce soda every day are 60 percent more likely to become obese than are those who do not.28 Poor eating and drinking habits in childhood matter because these dietary behaviors tend to persist into adulthood.29 Obesity also presents a significant societal burden. It negatively affects the economy by increasing the costs of direct medical services and human capital, decreasing productivity, and contributing to disability and premature mortality.30

DEFINITION

Acculturation is the process by which one cultural group adopts the beliefs and behaviors of another.

LATINOS ACCULTURATE TOWARD LESS HEALTHY DIETARY BEHAVIORS

Research shows that acculturation negatively influences dietary behaviors, including among many foreign-born Latinos who tend to eat healthier before adopting American behaviors. The more time Latinos spend in the United States, the more likely they are to develop unhealthy dietary practices and become obese.31 Latino families who acculturate are more inclined to eat at restaurants and consume sugary drinks than are Latino families who prepare more nutritious, traditional meals at home.32

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Sugary Drinks in Schools

School foods and beverages are critical sources of nutrition for children, who consume about 35 percent to 50 percent of their total daily calories at school.33 Per passage of the Healthy, Hunger-Free Kids Act of 2010, updated nutrition standards for the National School Lunch and Breakfast Programs went into effect in 2012, and similar standards known as “Smart Snacks in Schools” were implemented in 2014 for snacks and beverages sold in schools.

The “Smart Snacks in School” nutrition standards limit schools to selling only water, fat-free milk, non-flavored low-fat milk, and 100 percent fruit or vegetable juice during the school day, though they do not address sugary drinks marketed and/or sold outside of school time. Among other provisions, the Smart Snacks standards require that free drinking water be available to students on an unlimited basis. Water fountain availability, however, is still limited in many schools. Roughly four in 10 youths ages 9 to 19 report few functional water fountains or dispensers in their schools in a recent national survey, and one in 25 report no such resources.34 Underscoring the need for moderation and balance in student diets, the standards also set maximum portion sizes for permitted beverages based on students’ ages. These standards aim to reduce widespread access to sugary beverages and other unhealthy snack foods, which were often available in vending machines, à la carte lines, school stores and snack bars, classroom parties, and fundraisers.35 Fortunately, many schools across the nation have implemented the standards and taken additional proactive steps to reduce or eliminate sugary drinks with positive results.36

Unhealthy school snacks are particularly harmful to children from low-income families, who often suffer the burden of poor nutritional quality, as well as the peer pressure and stigma that drive students to buy snacks instead of healthier school meals.37 Moreover, schools with a higher proportion of minority students have historically had more access to sodas and weaker school policies regarding snack foods than schools with predominantly white students.38 These factors increase the likelihood that youth of color will consume more sugary drinks than their white peers. However, full implementation of the new Smart Snack guidelines across the country aims to remedy these disparities.

USDA “SMART SNACKS IN SCHOOL” NUTRITION STANDARDS

Require schools to make drinking water available to all students at no cost.

Permits schools to sell only water, fat-free milk, non-flavored low-fat milk, and 100-percent fruit or vegetable juice.

Introduce portion sizes for allowable beverages based on age.

Elementary schools are permitted to sell up to 8-ounce portions.

Middle and high schools can sell up to 12-ounce portions.

Create beverage options for older students.

High schools are permitted to sell calorie-free beverages in up to 20 ounce portions, and low calorie beverages with up to 40 calories in 8-ounce portions and up to 60 calories in 12 ounce portions.

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Impact of Marketing Sugary Drinks to Youth of Color

Advertisers spend about $866 million a year on television, print, and digital marketing aimed at selling sugary drinks.39 In addition, children (ages 6 to 11) and adolescents (ages 12 to 17) are exposed to about 269 and 287 of these advertisements, respectively, per year.40 Children and adolescents’ exposure to fast-food marketing is significantly higher—an estimated 1,168 and 1,752 advertisements per year, respectively.41

Strong evidence shows that television advertising influences young children’s short-term food consumption, food preferences, and caloric intake.42 Television advertisements still dominate youth-directed advertising, but beverage companies are increasingly shifting to digital marketing using social media, mobile devices, video games, and other web-based platforms to market sugary drinks, frequently to young children.43 Beverage companies also target children and adolescents through cross-promotions and product placement. For example, the product packaging for fruit drinks often feature licensed characters from children’s television shows and movies, such as SpongeBob SquarePants.44

Marketing efforts can also mislead people to believe that sugary drinks are healthy, especially when they are advertised as “all natural” or “real.” For example, sports drinks like Gatorade and Vitaminwater are often marketed as healthy alternatives to soda, which many parents believe.45 Their sugar content, however, comprises the majority of the product’s calories.46 The American Academy of Pediatrics recommends that most youths refrain from consuming sports drinks because they do not engage in enough physical activity to warrant their consumption.47 Nonetheless, sports drinks have a critical share of the market. In 2013, Gatorade spent $108 million on advertising in all media, the second most among all major sugary drink brands.48 African-American youth have also been found to be more than 60 percent more likely to visit Gatorade.com compared to the national average.49

Minority youth are more exposed to sugary drink advertisements and more heavily targeted by food, beverage, and fast-food companies than are white youth.50,51 (See Figure 3.) In part, this is because minority youth spend significantly more time watching television than do white youth.52 As such, many sugary drink advertisements strategically use minority celebrity icons, entertainers, and athletes to appeal to minority youth.53 In 2013, African-American children and teens saw more than double the number of television advertisements for sugary beverages and energy drinks than did their white peers.54 Youth of color are a desirable target for

DEFINITION

Cross-promotions are cooperative marketing tactics whereby two or more companies agree to promote each other’s products.

DEFINITION

Product placement occurs when a product, service, or trademark is either referenced or placed, visually or audibly, within mass-media programming.

7 Sugary Drinks in Communities of Color

advertisers because they tend to consume more media than general consumers do, use social networking to share opinions about products and brands, and are early adopters of new technology, often helping to set new trends.55

Advertisements for sugary drinks on Spanish-language television have been on the rise since 2008, likely a result of booming Latino population growth in the United States combined with deliberate strategies by companies to capitalize on the potential growth opportunity. In 2010, Latino preschoolers and teens viewed 33 percent and 49 percent more sugary beverage advertisements, respectively, on Spanish-language TV than in 2008. 57 Exposure increased again between 2010 and 2013 by 23 percent for Latino preschoolers and 32 percent for teens.58 Indeed, Latino preschoolers viewed almost 80 percent more advertisements for full-calorie Coca-Cola Classic on Spanish-language television than the average preschooler saw on English-language television.59 Additionally, Spanish-language television advertisements targeted at children are more likely to promote nutritionally poor food products than those on English-language channels. 60

Figure 3. Soda as a percentage of packaged food advertising during prime-time television programming by market56

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Industry’s Voluntary Commitments to Limit Advertising to Children

In response to growing public health concerns about the poor nutritional quality of foods and drinks marketed to children, the food and beverage industry has made efforts at self-regulation.61 In 2006, the Council of Better Business Bureaus established the Children’s Food and Beverage Advertising Initiative (CFBAI), whose member companies pledged to devote 100 percent of advertising targeted at children under age 12 to promote healthier or “better for you” products.62 During that same year, three leading beverage companies—Coca-Cola Company, PepsiCo, Inc., and Dr. Pepper Snapple Group—and the American Beverage Association made a commitment, in conjunction with the Alliance for a Healthier Generation, to create and implement voluntary School Beverage Guidelines that would “alter the mix of beverages available to students during the day.”63

Research is mixed as to whether industry self-regulation has significantly reduced the availability and consumption of sugary drinks among youths. Although CFBAI members have complied with their pledges, more than two-thirds of all CFBAI company advertising is still devoted to products of the poorest nutritional quality.64,65 Further, since establishing CFBAI and other self-regulatory groups, companies have significantly shifted their marketing tactics to focus more on teens and other topics

AMERICAN INDIAN HIGH SCHOOL STUDENTS CONSUME FEWER SUGARY DRINKS AFTER INTERVENTION

In an effort to counter steadily increasing rates of type 2 diabetes, the Zuni Pueblo tribe of New Mexico worked with the Zuni Public School District and the University of Arizona to implement a school-based diabetes prevention program. Before the intervention, students at Zuni High School were drinking, on average, 24 ounces of sugary beverages per week. The intervention educated students about the connection between unhealthy foods and diabetes, and provided healthy food and beverage alternatives including water in coolers. The program also replaced all regular sodas in vending machines with diet (sugar-free) sodas. Students made posters that alerted their peers to the link between unhealthy foods and diabetes, and placed them on vending machines and in the fitness center and school cafeteria. Following the intervention, the students showed significant and steady declines in plasma insulin levels, a marker for metabolic syndrome and type 2 diabetes. Three years after the intervention began, the 400 students of Zuni High School were consuming virtually no sugary drinks at school and were no longer bringing canned sodas to school.68

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SAN FRANCISCO LIMITS ACCESS TO SUGARY BEVERAGES AND INCREASES REVENUES FOR SCHOOLS

San Francisco—where more than 80 percent of the county’s public school students were from racial or ethnic minority populations in 2012—has taken several steps to limit access to sugary beverages in schools.69 In 1999, the city passed the Commercial-Free School Act, which prohibits the San Francisco Unified School District (SFUSD) from entering into an exclusive contract with a soda or snack food company and eliminates the use of curriculum materials that feature brand names.70 SFUSD also phased out the sale of sports drinks from schools and maintained stable à la carte food and beverage revenues, in part because administrators replaced unhealthy foods and beverages with healthier products requested by students.71 In fact, Aptos Middle School, the most racially and socioeconomically diverse middle school in the city, saw increased revenues after school administrators replaced sodas with bottled water in vending machines and à la carte lines.72 Another SFUSD school reaped a $3,000 net increase in food service revenue after one month due to increased school lunch participation.73 The success of such interventions led SFUSD to implement these changes throughout the district in 2003 and 2004.74

of marketing, such as digital, social and mobile media, that aren’t covered by their CFBAI pledges.66 Also, the validity of some research findings is questionable because studies funded by the beverage industry are four to eight times more likely to show a finding favorable to industry than independently funded studies.67

DEFINITION

In this context, exclusive contracts are agreements in which school districts agree to sell only one company’s products in vending machines and at all school events in exchange for direct payments from that company.

PHILADELPHIA’S OBESITY RATES DROP FOLLOWING PASSAGE OF COMPREHENSIVE POLICIES TO EXPAND HEALTHY EATING AND PHYSICAL ACTIVITY

The city of Philadelphia, which is more than 43 percent African-American, has taken several steps to improve its local food system and the health of its neighborhoods and schools.75 In 2010, Mayor Michael Nutter and the city’s Department of Public Health spearheaded “Get Healthy Philly,” a collaborative, multi-sector initiative to improve nutrition and physical activity.76 In two years, this initiative helped enable more than 630 corner stores to sell healthier foods and beverages, including produce, water, and low-fat dairy products. Get Healthy Philly also launched a media campaign to raise public awareness about the link between sugary drinks, obesity, and diabetes that was seen or heard more than 40 million times.

With respect to schools, Philadelphia passed a district-wide beverage policy in 2004 that restricted vending machine and à la carte sales on school premises to 100-percent juice, water, and low- or non-fat milk.77 School administrators also created school wellness councils in 171 public schools, reaching more than 100,000 students, and worked to remove unhealthy foods including sugary drinks from classrooms, school stores, and fundraisers. These changes may have contributed to an overall drop of nearly 5 percent in the obesity rates of Philadelphia students in grades K-12 from 2006 to 2010.78

DEFINITION

School wellness councils are advisory groups concerned with the health and wellbeing of students and staff. Councils typically include school staff, students, family members, and community members.

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Policy Options

While policymakers face difficult challenges to limiting the role of sugary drink marketing and consumption in communities of color, there are also opportunities for action. Policymakers representing schools, cities, counties, and states can use public policy to reduce access to these beverages and promote healthier alternatives for their constituents. The following highlights some effective policy options.

School-Based Policies:

• Create Comprehensive Wellness Policies and School Wellness Councils In accordance with the Healthy, Hunger-Free Kids Act of 2010, schools participating in the National School Lunch Program or other federal child nutrition programs need to strengthen and fully implement local school wellness policies to improve student nutrition and health.79 This includes permitting school-based food and/or drink advertisements or marketing only for those items that meet the Smart Snack guidelines. In addition to establishing goals for promoting healthy foods and beverages, physical activity, and student wellness, schools are required to ensure participation of all relevant stakeholders in the review and implementation of the local school wellness policy. This can be accomplished through the creation of a school wellness council.

Ideally, school wellness councils should include school administrators, physical education and health teachers, food service staff, students, family members, and community members such as parks and recreation representatives. These stakeholder groups can be given important responsibilities such as identifying ways to improve the health of students and staff, coordinating nutrition education programs, and monitoring the implementation of comprehensive school wellness policies. Councils can also promote student engagement by directly involving them in such activities as tasting sample beverages, designing healthy beverage marketing campaigns, and selecting healthy drinks for vending machines. Because many changes will directly affect students, their input and support throughout the process is often critical to success.80 School administrators and wellness councils should clearly communicate the rationale for any decisions to reduce or eliminate access to sugary drinks with all stakeholders throughout the process.

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• Fully Implement USDA’s Smart Snacks in Schools Guidelines

Limit the Availability of Sugary Drinks During the School Day: School administrators should ensure the availability of healthy food and beverage options during the school day in cafeterias, vending machines, snack bars, and any other venue offering foods and beverages.

Increase Healthy Food and Beverage Availability: Under the Smart Snacks in Schools guidelines, drinking water must be available to students at no cost during all school meals. School water fountains should be accessible and maintained regularly so that children have the ability and desire to use them. School administrators can promote water consumption further by providing cups and containers, water dispensers, water bottles, or chilled or filtered drinking stations. They can also involve students in developing social marketing plans to encourage their classmates to drink water.

• Change Food Marketing Practices School administrators should not only restrict the marketing of sugary drinks in schools, they should also implement social marketing strategies to promote healthier beverages such as water. Other potential actions could include reviewing marketing practices in existing contracts with beverage companies and prohibiting exclusive contracts—which can limit options for schools—in the future.81

• Promote Nutrition Education Schools and local governments should promote culturally relevant nutrition education programs for communities of color. They can partner with universities, health departments, and community- or faith-based organizations to disseminate information to parents and the local community. School administrators should communicate with parents and caregivers about what the school or district is doing to improve student nutrition and how parents and caregivers can encourage students to drink healthy beverages. Such information should be communicated with parents in culturally appropriate languages.

• Limit Sugary Drink Sales on School Premises Before and After School, and at Other Child-Centered Locations It is also critical to limit the sale of sugary drinks on school premises before and after the school day, particularly during sports events. Current USDA standards do not include provisions regarding the sale of beverages outside of school hours. School administrators should consider going beyond the existing standards and follow best practices to implement these rules.

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Community-Based Policies:

Local governments can launch multi-sector campaigns to raise public awareness about the health consequences of excessive sugary drink consumption. They can also create social marketing campaigns to promote healthy beverages such as those launched in New York City,82 Philadelphia,83 Kansas City, Kan.,84 Santa Clara, Calif.,85 and Howard County, Md.86 Additionally, community- and faith-based organizations can set positive examples by adopting their own healthy workplace policies that encourage serving healthier beverages where and when they meet. Workplace policies, such as those that influence the type of food and drinks available during meetings or in the office setting, can be designed to help promote employee health.87 Local leaders can also advance policies that restrict the availability and marketing of sugary beverages, particularly to youth.

• Ensure that Government Facilities and Government-Sponsored Events Promote Citizens’ Health Local governments can set a good example for schools and neighborhoods by providing only healthy beverage options in their facilities and promoting healthy beverages at city- and county-sponsored programs and events, especially those attended by children, such as after-school programs and parks and recreational facilities. Officials should eliminate sugary drink sponsorships and advertising at city and county events, including sports leagues, facilities, and programs. The San Francisco Unified School District sought to address this issue with its Commercial-Free Schools Act, which requires approval by the Board of Education for any corporate sponsorship of athletic teams or clubs.88 Water fountains should be provided in all public venues where beverages are available, including schools, parks, and government buildings. Similarly, community- and faith-based organizations can be encouraged to serve healthier beverages in their after-school and summer programs.

• Make Restaurants Healthier for All One-third of the sugary drinks Americans consume away from home are obtained in restaurants or fast-food establishments.89 In 2011, the Food and Drug Administration (FDA) proposed a rule that would establish requirements for nutrition labeling of standard food and drink items on menus and menu boards in chain restaurants and similar retail food establishments with 20 or more locations.90 The final rule, issued in 2014, covers not only chain restaurants but also grocery stores, convenience stores, and other food service establishments like movie theaters and pizza parlors.91 In addition to the posting of calories, additional nutrient information (such as total sugars) must be made available upon request. Food establishments should properly implement these new regulations. Though not subject to the current rule, non-chain restaurants should consider following it on a voluntary basis.

DEFINITION

Social marketing is an approach that uses traditional marketing techniques and concepts to influence individual behavior for the betterment of both the individual and his or her community.

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• Support Healthy Community Design Local governments can also establish minimum distances between fast-food restaurants and places that children frequent, such as schools or playgrounds. At fast-food restaurants such as McDonald’s, sugary drinks can account for more than 40 percent of drinks ordered with a kids’ meal.92 As counties and cities review their zoning policies, they can identify opportunities to limit new fast-food restaurants from opening near schools. Detroit, Mich. and Arden Hills, Minn., for example, both have local ordinances that prohibit fast-food restaurants from being located within 500 feet of elementary, middle, or high schools.93

• Increase Consumer Awareness to Encourage Healthy Choices Local governments can help provide consumers with the information they need to make healthier choices. They can help educate consumers about products marketed as healthy alternatives to soda, such as fruit drinks, sports drinks, and flavored water, which often contain significant amounts of sugar.

• Use Sugary Drink Tax Revenues for Obesity-Prevention Initiatives State and local officials can consider levying excise taxes on sugary beverages in an effort to reduce consumption directly through higher prices. The revenues generated by the tax can then be applied to nutrition education and obesity-prevention initiatives, especially targeting vulnerable communities.96 A 2011 study estimated that a national penny-per-ounce tax on sugary drinks would generate $79 billion over the period of 2010 to 2015.97 Several experts have also suggested that earmarking these tax revenues for obesity prevention and reduction efforts would improve weight outcomes.98 Such taxes have the potential to cut consumption as evidenced by the public health success of reduced tobacco use from taxes.99 While some states have levied relatively small sales taxes on certain unhealthy beverages, research suggests that sugary drink taxes need to be as high as 20 percent to result in significant weight loss.100 In 2014, Berkeley, Calif. became the first city in the U.S. to pass a law taxing sugary drinks.101 The new law, receiving roughly 75 percent of votes, established a penny-per-ounce tax.

HOSPITALS USE INNOVATIVE STRATEGIES TO PROMOTE HEALTHY DRINKS IN CAFETERIAS

Ten Boston hospitals partnered with the city’s government in 2012 to implement innovative point-of-sale strategies to promote healthy drinks in their cafeterias. The hospitals established a “red-yellow-green” stoplight system to help consumers choose healthier options, increased the visibility of healthy beverages by putting them at the consumers’ eye-level, and installed free water dispensers.94 An evaluation of the initiative found that 50 percent more customers reported looking at nutrient information after the intervention and that those who saw the information were more likely to purchase healthier items.95 Many hospitals around the country have since emulated Boston’s policies by creating healthier environments for patients, staff, and visitors.

DEFINITION

An excise tax is a tax on a specific good or service. It can be either a specific excise tax based on quantity—for example, a gallon of gasoline or a pack of cigarettes—or an ad valorem excise tax based on the value or price of the item sold. Excise taxes are typically levied on producers or wholesalers, who pass on the cost to retailers and ultimately to consumers.

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Conclusion

Growing research connecting the consumption of sugary drinks to obesity, type 2 diabetes, tooth decay, and other chronic conditions highlights a clear imperative for policy changes. Sugary drink marketing also continues to target the most vulnerable communities, including communities of color, but research shows that there are many effective policy options for reducing the marketing of these beverages and increasing the availability of more nutritious choices. Schools are an important area of focus because children consume a large share of their daily calories at school, and significant policy advances are already underway. However, policymakers must continue to explore a variety of levers to reduce sugary drink consumption and ensure that existing federal guidelines are fully implemented. Continued progress in preventing childhood obesity in America must include policy efforts to limit sugary drink marketing and consumption in communities of color and increase access to healthier alternatives.

Resources Rudd Center for Food Policy & Obesity: Sugary Drink FACTS 2014

Center for Science in the Public Interest: “Sugar Drinks”

African-American Collaborative Obesity Research Network: “Impact of Sugar-Sweetened Beverage Consumption on Black Americans’ Health”

Salud America: The RWJF Research Network to Prevent Obesity Among Latino Children

Rudd Center for Food Policy & Obesity: “Fast Food FACTS 2013: Measuring Progress in Nutrition and Marketing to Children and Teens”

Berkeley Media Studies Group: “The New Age of Food Marketing”

Bridging the Gap: “Availability of Competitive Foods and Beverages”

Bridging the Gap: “Beverage and Snack Taxes”

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Additional ReferencesBleich SN, Wang YC, Wang Y and Gortmaker SL. 2009. “Increasing Consumption of Sugar-Sweetened Beverages Among U.S. Adults: 1988-1994 to 1999-2004.” American Journal of Clinical Nutrition, 89(1): 372-381.

Centers for Disease Control and Prevention. 2011. “National Diabetes Fact Sheet: National Estimates and General Information on Diabetes and Prediabetes in the United States. Atlanta, GA: Centers for Disease Control and Prevention.” http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.

Drinking Water for Students in Schools. 2012. Sacramento, CA: California Department of Education, July. http://www.cde.ca.gov/ls/nu/he/water.asp.

Flegal KM, Carroll MD, Ogden CL and Curtin LR. 2010. “Prevalence and Trends in Obesity Among U.S. Adults, 1999-2008.” Journal of the American Medical Association, 303(3):235-241.

Harris JL, Weinberg ME, Schwartz MB, Ross C, Ostroff J and Brownell KD. 2010. Trends in Television Food Advertising: Progress in Reducing Unhealthy Marketing to Young People? New Haven, CT: Rudd Center for Food Policy and Obesity, 2010. http://www.yaleruddcenter.org/resources/upload/docs/what/reports/RuddReport_TVFoodAdvertising_2.10.pdf.

Horizon Foundation, Howard County Unsweetened. http://www.hocounsweetened.org/.

Kansas Department of Health and Environment, Refresh Kansas. http://www.refreshkansas.org/.

Malik VS, Schulze MB and Hu FB. 2006. “Intake of Sugar-Sweetened Beverages and Weight Gain: A Systematic Review.” American Journal of Clinical Nutrition, 84(2):274-288.

New York City Department of Health and Mental Hygiene. “Information and Resources for Your Health.” http://www.nyc.gov/html/doh/html/living/cdp_pan_pop.shtml.

Philadelphia Department of Public Health, Food Fit Philly. http://www.foodfitphilly.org/.

Powell LM, Schermbeck RM, Szczypka G, Chaloupka FJ and Braunschweig CL. 2011. “Trends in the Nutritional Content of Television Food Advertisements Seen by Children in the United States: Analyses by Age, Food Categories, and Companies.” Archives of Pediatrics & Adolescent Medicine, 165(12):1078-1086.

Santa Clara County Public Health, “ReThink Your Drink.” County of Santa Clara SCCGOV http://www.sccgov.org/sites/sccphd/en-us/residents/rethinkyourdrink/Pages/default.aspx.

Senate Bill No. 1413. State of California. September 30, 2010. http://www.leginfo.ca.gov/pub/09-10/bill/sen/sb_1401-1450/sb_1413_bill_20100930_chaptered.pdf.

Sonestedt E, Overby NC, Laaksonen DE and Birgisdottir BE. 2012. “Does High Sugar Consumption Exacerbate Cardiometabolic Risk Factors and Increase the Risk of Type 2 Diabetes and Cardiovascular Disease?” Food Nutrition Research, 56:19104.

Tahmassebi JF, Duggal MS, Malik-Kotru G and Curzon ME. 2006. “Soft Drinks and Dental Health: A Review of the Current Literature.” Journal of Dentistry , (34)1:2-11.

Te Morenga L, Mallard S and Mann J. 2013. “Dietary Sugars and Body Weight: Systematic Review and Meta-Analyses of Randomized Controlled Trials and Cohort Studies.” British Medical Journal, 345(7492): 1-25.

Vartanian LR, Schwartz MB and Brownell KD. 2007. “Effects of Soft Drink Consumption on Nutrition and Health: A Systematic Review and Meta-Analysis.” American Journal of Public Health, 97(4): 667-675.

16 Sugary Drinks in Communities of Color

1 Malik VS, Popkin BM, Bray GA, Despres JP, Willett WC, Hu FB. 2010. “Sugar-Sweetened Beverages and Risk of Metabolic Syndrome and Type 2 Diabetes: A Meta-Analysis. Diabetes Care 33(11):2477-2483.

2 Kit BK, Fakhouri THI, Park S, Nielsen SJ and Ogden CL. 2013.”Trends in Sugar-Sweetened Beverage Consumption Among Youth and Adults in the United States: 1999-2010.” American Journal of Clinical Nutrition 98(1):180-188.

3 Taveras EM, Gillman MW, Kleinman K, Rich-Edwards JW and Rifas-Shiman SL. 2010. “Racial/Ethnic Differences in Early-Life Risk Factors for Childhood Obesity.” Pediatrics, 125:686-695.

4 Ogden CL, Kit BK, Carroll MD and Park S. 2011. Consumption of Sugar Drinks in the United States, 2005-2008. Hyattsville, MD: Centers for Disease Control and Prevention and National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db71.pdf. Accessed July 2013.

5 U.S. Department of Agriculture, ChooseMyPlate.gov. Calories: How Many Can I Have? http://www.choosemyplate.gov/weight-management-calories/calories/empty-calories-amount.html. Accessed December 9, 2014.

6 Ogden CL, Kit BK, Carroll MD and Park S. 2011. Consumption of Sugar Drinks in the United States, 2005-2008. Hyattsville, MD: Centers for Disease Control and Prevention and National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db71.pdf. Accessed July 2013.

7 Lloyd-Jones DM, Hong Y, Labarthe D et al. 2010. Defining and Setting National Goals for Americans, 2010. 7th edition. Washington, DC: U.S. Government Printing Office. http://www.cnpp.usda.gov/DietaryGuidelines.htm. Accessed July 2013.

8 Ogden CL, Kit BK, Carroll MD and Park S. 2011.Consumption of Sugar Drinks in the United States, 2005-2008. Hyattsville, MD: Centers for Disease Control and Prevention and National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db71.pdf. Accessed July 2013. Han E and Powell LM. 2013. “Consumption Patterns of Sugar-Sweetened Beverages in the United States.” Journal of Academic Nutrition and Dietetics 113:43-53.

9 Beck AL, Patel A and Madsen K. 2013.”Trends in Sugar-Sweetened Beverage and 100% Fruit Juice Consumption Among California Children.” Academic Pediatrics 13(4):1-7.

10 Ogden CL, Kit BK, Carroll MD and Park S. 2011. Consumption of Sugar Drinks in the United States, 2005-2008. Hyattsville, MD: Centers for Disease Control and Prevention and National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db71.pdf. Accessed July 2013.

11 Beaulac J, Kristjansson E and Cummins S. 2009. “A Systematic Review of Food Deserts, 1966-2007.” Preventing Chronic Disease 6(3):1-10.

12 Morland K, Wing S, Diez Roux A and Poole C. 2002. “Neighborhood Characteristics Associated with the Location of Food Stores and Food Service Places.” American Journal of Preventive Medicine 22(1):23-29. Zenk SN, Schulz AJ, Israel BA, et al. 2005. “Neighborhood Racial Composition, Neighborhood Poverty, and the Spatial Accessibility of Supermarkets in Metropolitan Detroit.” American Journal of Public Health 95(4):660-667. .

13 Pothukuchi K. 2005. “Attracting Supermarkets to Inner-City Neighborhoods: Economic Development Outside the Box.” Economic Development 19(3):232-244. Glanz K, Sallis JF, Saelens BE, et al. 2007. “Nutrition Environment Measures Survey in Stores (NEMS-S): Development and Evaluation.” American Journal of Preventive Medicine 32(4):282-289..

14 Powell LM, Slater S, Mirtcheva D, et al. 2007. “Food Store Availability and Neighborhood Characteristics in the United States.” Preventative Medicine 44(3):189-195.

15 Nyberg K, Ramirez A and Gallion K. 2011. “Addressing Nutrition, Overweight and Obesity Among Latino Youth.” Salud America! Trenton, NJ: Robert Wood Johnson Foundation.

16 Agricultural Marketing Service, U.S. Department of Agriculture. “Food Deserts.” http://apps.ams.usda.gov/fooddeserts/foodDeserts.aspx. Accessed October 21, 2013.

17 Centers for Disease Control and Prevention.2014.National Diabetes Statistics Report: Estimates of Diabetes and Its Burden in the United States, 2014. Atlanta, GA: US Department of Health and Human Services.. http://www.cdc.gov/diabetes/pdfs/data/2014-report-estimates-of-diabetes-and-its-burden-in-the-united-states.pdf. Accessed November 2014.

18 Palmer JR, Boggs DA, Krishnan S, Hu FB, Singer M and Rosenberg L. 2008. “Sugar-Sweetened Beverages and Incidence of Type 2 Diabetes Mellitus in African-American Women.” Archives of Internal Medicine 168(14):1487-1492.

19 Nalliah RP, Allareddy V, Elangovan S, Karimbux N and Allaredy V. 2010. “Hospital Based Emergency Department Visits Attributed to Dental Caries in the United States in 2006.” Journal of Evidence Based Dental Practice 10(4):212-222.

20 Lim S, Sohn W, Burt BA, et al. 2008.”Cariogenicity of Soft Drinks, Milk, and Fruit Juice in Low-Income African-American Children: a Longitudinal Study.” Journal of the American Dental Association 139(7):959-967.

21 Oral Health in America: A Report of the Surgeon General. 2000. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health. http://silk.nih.gov/public/hck1ocv.@www.surgeon.fullrpt.pdf. Accessed July 19, 2013. Dye BA, Tan S, Smith V, et al. 2007. Trends in Oral Health Status: United States, 1988-1994 and 1999-2004. Series 11, Number 248. Hyattsville, MD: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics.

22 Ogden CL, Carroll MD, Kit BK, and Flegal KM. 2014. “Prevalence of Childhood and Adult Obesity in the United States, 2011-2012.” Journal of the American Medical Association 311(8):806-814.

23 Flegal KM, Carroll MD, Kit BK and Ogden CL. 2012. “Prevalence of Obesity and Trends in the Distribution of Body Mass Index Among U.S. Adults, 1999-2010.” Journal of American Medical Association 307(5): 491-497. Ogden CL, Carroll MD, Kit BK and Flegal KM. 2012. “Prevalence of Obesity and Trends in Body Mass Index Among U.S. Children and Adolescents, 1999-2010.” Journal of the American Medical Association 307(5): 483-490.

Endnotes

17 Sugary Drinks in Communities of Color

24 Pan A and Hu FB. 2011. “Effects of Carbohydrates on Satiety: Differences Between Liquid and Solid Food.” Current Opinions in Clinical Nutrition and Metabolic Care 14:385-390.

25 Ogden CL, Carroll MD, Kit BK, and Flegal KM. 2014. “Prevalence of Childhood and Adult Obesity in the United States, 2011-2012.” Journal of the American Medical Association 311(8):806-814.

26 Ogden CL, Carroll MD, Kit BK and Flegal KM. 2012. “Prevalence of Obesity and Trends in Body Mass Index Among U.S. Children and Adolescents, 1999-2010.” Journal of the American Medical Association307(5): 483-490.

27 Dalenius K, Borland E, Smith B, Polhamus B, Grummer-Strawn L. 2012. Pediatric Nutrition Surveillance 2010 Report. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention. www.cdc.gov/pednss/pdfs/PedNSS_2010_Summary.pdf. Accessed June 2013.

28 Ludwig DS, Peterson KE and Gortmaker SL. 2001. “Relation between Consumption of Sugar-Sweetened Drinks and Childhood Obesity: A Prospective Observational Analysis.” The Lancet 357:505-508.

29 Craigie AM, Lake AA, Kelly SA, Adamson AJ and Mathers JC. 2011. “Tracking of Obesity-Related Behaviors from Childhood to Adulthood: A Systematic Review.” Maturitas, 70(3):266-284.

30 Hammond RA and Levine R. 2010. “The Economic Impact of Obesity in the United States.” Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 3:285-295.

31 Barcenas CH, Wilkinson AV, Strom SS, et al. 2007. “Birthplace, Years of Residence in the United States, and Obesity Among Mexican-American Adults.” Obesity 15:1043-1052.

32 Mainous AG, Majeed A, Koopman RJ, et al. 2006. “Acculturation and Diabetes Among Hispanics: Evidence from 1999-2002 National Health and Nutrition Examination Survey.” Public Health Reports 121:60-6. Ayala GX, Baquero B and Klinger S. 2008. “ Systematic Review of the Relationship between Acculturation and Diet Among Latinos in the United States: Implications for Future Research.” Journal of American Dietetic Association 108:1330-1344; Nyberg K, Ramirez A and Gallion K.2011. “Addressing Nutrition, Overweight and Obesity Among Latino Youth.” Salud America! Trenton, NJ: Robert Wood Johnson Foundation, p. 6.

33 Robert Wood Johnson Foundation. 2013. How Can Healthier School Snacks and Beverages Improve Student Health and Help School Budgets? Healthy Policy Snapshot Series, Issue Brief, February. http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf72649. Accessed August 2013.

34 Onufrak SJ, Park S, Wilking C. Student-Reported School Drinking Fountain Availability by Youth Characteristics and State Plumbing Codes. Prev Chronic Dis. 2014;11:130314. DOI: http://dx.doi.org/10.5888/pcd11.130314

35 Food Research and Action Center. 2013. USDA Smart Snacks in School Rule: What You Need to Know.. https://s3.amazonaws.com/pnmresources/pID-342/FRAC%202.14.2013%20Ppt.%20Slides%20(1%20Per%20Page).pdf. Accessed June 2013.

36 Turner L and Chaloupka FJ. 2010. Availability of Competitive Foods and Beverages: New Findings from U.S. Elementary Schools. Kansas City, MO: Bridging the Gap, June. http://www.bridgingthegapresearch.org/_asset/qvb125/BTG_Brief_Competitive_Foods_Beverages_June_2010_final.pdf. Accessed June 2013.

37 Terry-McElrath YM, O’Malley PM and Johnston LD. 2013.”School Soft Drink Availability and Consumption Among U.S. Secondary Students.” American Journal of Preventive Medicine 44(6):573-582.

38 Ibid. Taber DR, Chriqui JF, Perna FM, Powell LM and Chaloupka FJ. 2012. “Weight Status Among Adolescents in States that Govern Competitive Food Nutrition Content.” Pediatrics130(3):437-444.

39 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

40 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

41 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

42 Institute of Medicine. 2006. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press. Borzekowski DL and Robinson TN.2001. “The 30-Second Effect: An Experiment Revealing the Impact of Television Commercials on Food Preferences of Preschoolers.” Journal of the American Dietetic Association 101(1): 42-46. Halford JCG, Boyland EJ, Hughes G, Oliveira LP and Dovey TM.2007. “Beyond-Brand Effect of Television (TV) Food Advertisements/Commercials on Caloric Intake and Food Choice of 5-7-Year-Old Children.” Appetite 49(1): 263-267.

43 Institute of Medicine. 2006. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press. The New Age of Food Marketing. 2011. Oakland, CA: Berkeley Media Studies Group, October. http://www.bmsg.org/sites/default/files/digitalads_brief_report.pdf. Accessed June 2013.

44 Harris JL, Schwartz MB and Brownell KD. 2009. “Marketing Foods to Children and Adolescents: Licensed Characters and Other Promotions on Packaged Foods in the Supermarket.” Public Health Nutrition 13(3): 409-417.

18 Sugary Drinks in Communities of Color

45 Healthy Eating Research. 2012. Consumption of Sports Drinks by Children and Adolescents. Minneapolis: Healthy Eating Research. http://healthyeatingresearch.org/wp-content/uploads/2013/12/HER-Sports-Drinks-Research-Review-6-2012.pdf. Accessed January 20, 2015.

46 Story M and Klein L. 2012. Consumption of Sports Drinks by Children and Adolescents. Minneapolis, MN: Healthy Eating Research, June. http://www.healthyeatingresearch.org/images/stories/her_research_briefs/IBSportsDrinkFINAL6-2012_WEB.pdf. Accessed June 17, 2013.

47 American Academy of Pediatrics. 2011. “Kids Should Not Consume Energy Drinks, and Rarely Need Sports Drinks, Says AAP.” May 30. http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Kids-Should-Not-Consume-Energy-Drinks,-and-Rarely-Need-Sports-Drinks,-Says-AAP.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token. Accessed July 10, 2013.

48 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

49 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

50 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

51 Aaker JL, Brumbaugh AM and Grier SA. “Nontarget Markets and Viewer Distinctiveness: The Impact of Target Marketing on Advertising Attitudes.” Journal of Consumer Psychology 2000;9(3):127-140; The New Age of Food Marketing. 2011. Oakland, CA: Berkeley Media Studies Group, October. http://www.bmsg.org/resources/publications/the-new-age-of-food-marketing. Accessed June 2013..

52 Institute of Medicine. 2006. Food Marketing to Children and Youth: Threat or Opportunity? Washington, DC: The National Academies Press.

53 Robbins, J. 2010. “The Dark Side of Vitaminwater.” The Huffington Post. August 5. http://www.huffingtonpost.com/john-robbins/the-dark-side-of-vitaminw_b_669716.html. Accessed July 10, 2013.

54 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

55 Huang C. 2009. “What Social Media Can Learn from Multicultural Marketing.” Advertising Age, September 8. http://adage.com/bigtent/post?article_id=138864. Accessed June 15, 2013; Grier, S. 2009. African American & Hispanic Youth Vulnerability to Target Marketing: Implications for Understanding the Effects of Digital Marketing. Berkeley, CA: NPLAN Marketing to Children Learning Community, June. http://changelabsolutions.org/sites/default/files/documents/Targeted_marketing_to_Hisp_and_AA_youth.pdf. Accessed June 2013.

56 Outley CW and Taddese A.2006. “A Content Analysis of Health and Physical Activity Messages Marketed to African American Children During After-School Television Programming.” Archives of Pediatrics & Adolescent Medicine 160(4):432-435.

57 Harris JL, Schwartz MB, Brownell KD, et al. 2011. Sugary Drink FACTS: Evaluating Sugary Drink Nutrition and Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October . http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed June 2013.

58 Harris JL, Schwartz MB, LoDolce M, et al. 2014. Sugary Drink FACTS 2014: Some Progress But Much Room For Improvement in Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October. http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed November 25, 2014.

59 Harris JL, Schwartz MB, Brownell KD, et al. 2011. Sugary Drink FACTS: Evaluating Sugary Drink Nutrition and Marketing to Youth. New Haven, CT: Rudd Center for Food Policy and Obesity, October . http://www.sugarydrinkfacts.org/resources/SugaryDrinkFACTS_Report.pdf. Accessed June 2013.

60 Kunkel D, Mastro D, Ortiz M and McKinley C. 2013. “Food Marketing to Children on U.S. Spanish-Language Television”. Journal of Health Communication, 18, 1084-1096.

61 Wescott RF, Fitzpatrick BM and Phillips E. 2012. “Industry Self-Regulation to Improve Student Health: Quantifying Changes in Beverage Shipments to Schools.” American Journal of Public Health, 102(10): 1928-1935.

62 CFBAI’s Category-Specific Uniform Nutrition Criteria. 2013. Arlington, VA: Council of Better Business Bureaus, June.. http://www.bbb.org/us/storage/16/documents/cfbai/CFBAI%20Uniform%20Nutrition%20Criteria%20Fact%20Sheet%20-FINAL.pdf. Accessed July 2013.

63 Wescott RF, Fitzpatrick BM and Phillips E. 2012. “Industry Self-Regulation to Improve Student Health: Quantifying Changes in Beverage Shipments to Schools.” American Journal of Public Health, 102(10): 1928-1935.

64 Harris JL, Sarda V, Schwartz MB, Brownell KD. 2013. “Redefining ‘Child-directed Advertising’ to Reduce Unhealthy Television Food Advertising.” Am J Prev Med, 44(4):358-364.

65 Kunkel D, McKinley C and Wright P. 2009. The Impact of Industry Self-Regulation on the Nutritional Quality of Foods Advertised on Television to Children. Oakland, CA: Children Now., http://www.childrennow.org/uploads/documents/adstudy_2009.pdf. Accessed July 2013.

66 The New Age of Food Marketing. 2011. Oakland, CA: Berkeley Media Studies Group, October. http://www.bmsg.org/sites/default/files/digitalads_brief_report.pdf. Accessed June 2013.

19 Sugary Drinks in Communities of Color

67 Lesser LI, Ebbeling CB, Goozner M, Wypij D and Ludwig DS. 2007. “Relationship Between Funding Source and Conclusion Among Nutrition-Related Scientific Articles.” PLOS Medicine ,4:e5.

68 Ritenbaugh C, Teufel-Shone NI, Aickin MG, et al. 2003. “A Lifestyle Intervention Improves Plasma Insulin Levels among Native American High School Youth.” Preventive Medicine, 36(3):309-319.

69 Public School Enrollment, by Race/Ethnicity: 2012. 2013. Palo Alto, CA: Lucile Packard Foundation for Children’s Health. http://www.kidsdata.org/data/topic/table/public_school_enrollment-race.aspx. Accessed July 2013.

70 Wynns J and Chin EY. 1999. The Commercial-Free Schools Act. Resolution No. 95-25A6. San Francisco: June. http://www.sfgov3.org/ftp/uploadedfiles/sffood/policy_reports/commercialfree1999.pdf. Accessed July 2013.

71 Kleske D, Walter C, Cowling L, Berends V and Agron P. 2013. Eliminating Electrolyte Replacement Beverages in California Public Schools. Sacramento, CA: California Project Lean. http://www.californiaprojectlean.org/docuserfiles/Case%20Studies_ERBs_web.pdf. Accessed June 2013.

72 United States Department of Agriculture, the Division of Adolescent and School Health of the Centers for Disease Control and Prevention, Department of Health and Human Services and the United States Department of Education. 2005. Making it Happen! Nutrition Success Stories. 2005. l.http://www.fns.usda.gov/tn/making-it-happen-school-nutrition-success-stories. Accessed July 2013.

73 Wojcicki JM and Heyman MB. 2006. “Healthier Choices and Increased Participation in Middle School Lunch Program: Effects of Nutrition Policy Changes in San Francisco.” American Journal of Public Health,96(9):1542-1547.

74 United States Department of Agriculture, the Division of Adolescent and School Health of the Centers for Disease Control and Prevention, Department of Health and Human Services and the United States Department of Education. 2005. Making it Happen! Nutrition Success Stories. 2005. l.http://www.fns.usda.gov/tn/making-it-happen-school-nutrition-success-stories.. Accessed July 2013.

75 United States Census Bureau. 2013. “Philadelphia (city), Pennsylvania” in State and County QuickFacts. http://quickfacts.census.gov/qfd/states/42/4260000.html. Updated June 27. Accessed July 19, 2013.

76 Philadelphia Department of Public Health, 2012. Healthy Eating and Active Living: Making the Healthy Choice the Easy Choice, Annual Report 2011-2012.. http://www.phila.gov/health/pdfs/commissioner/2012AnnualReport_Nutrition.pdf. Accessed June 2013.

77 Ibid.

78 Robbins JM, Mallya G, Polansky M and Schwarz DF. 2012. “Prevalence, Disparities, and Trends in Obesity and Severe Obesity Among Students in the Philadelphia, Pennsylvania, School District, 2006-2010.” Preventing Chronic Disease, 9:120118.

79 Food and Nutrition Service, U.S. Department of Agriculture. 2014. “Local School Wellness Policy.” http://www.fns.usda.gov/tn/local-school-wellness-policy. Last Modified July 21. Accessed November 3, 2014.

80 Kleske D, Walter C, Cowling L, Berends V and Agron P. 2013. Eliminating Electrolyte Replacement Beverages in California Public Schools. Sacramento, CA: California Project Lean. http://www.californiaprojectlean.org/docuserfiles/Case%20Studies_ERBs_web.pdf. Accessed June 2013.

81 Khan LK, Sobush K, Keener, D, et al. 2009. Recommended Community Strategies and Measurements to Prevent Obesity in the United States. Washington, DC: United States Department of Health & Human Services, Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5807a1.htm. Accessed June 2013.

82 New York City Department of Health and Mental Hygiene. Information and Resources for Your Health. http://www.nyc.gov/html/doh/html/living/cdp_pan_pop.shtml.

83 Philadelphia Department of Public Health. Food Fit Philly. http://www.foodfitphilly.org/.

84 Kansas Department of Health and Environment. Refresh Kansas. http://www.refreshkansas.org/.

85 Santa Clara County Public Health. ReThink Your Drink. http://www.sccgov.org/sites/sccphd/en-us/residents/rethinkyourdrink/Pages/default.aspx.

86 The Horizon Foundation. Howard County Unsweetened. http://www.hocounsweetened.org/.

87 Centers for Disease Control and Prevention. 2013. Workplace Health Promotion: Health-related Policies. http://www.cdc.gov/workplacehealthpromotion/implementation/policies.html. Accessed February 10, 2015.

88 Wynn J, Chin EY. The Commercial-Free Schools Act. (Prohibiting Exclusive Vendor Contracts, Brand Names, and Tobacco Subsidiary Food Products). http://eatbettermovemore.org/sa/policies/pdftext/SF%20Commerical-%20Free%20Schools.pdf. Accessed January 20, 2015.

89 Ogden CL, Kit BK, Carroll MD and Park S. 2011. Consumption of Sugar Drinks in the United States, 2005-2008. Hyattsville, MD: Centers for Disease Control and Prevention and National Center for Health Statistics. http://www.cdc.gov/nchs/data/databriefs/db71.pdf. Accessed July 2013.

90 U.S. Food and Drug Administration, U.S. Department of Health & Human Services. 2013. Overview of FDA Proposed Labeling Requirements for Restaurants, Similar Retail Food Establishments and Vending Machines. http://www.fda.gov/Food/IngredientsPackagingLabeling/LabelingNutrition/ucm248732.htm. Last updated April 24. Accessed October 2013.

91 Food and Drug Administration, Department of Health and Human Services. Food Labeling; Nutrition Labeling of Standard Menu Items in Restaurants and Similar Retail Food Establishments, Final Rule. Docket No. FDA-2011-F-0172. https://s3.amazonaws.com/public-inspection.federalregister.gov/2014-27833.pdf.

92 Harris JL, Schwartz MB, Munsell CR, et al. 2013. Fast Food FACTS 2013: Measuring Progress in Nutrition and Marketing to Children and Teens. New Haven: Rudd Center for Food Policy & Obesity. http://www.fastfoodmarketing.org/media/FastFoodFACTS_report.pdf. Accessed January 20, 2015.

93 Mair JS, Pierce MW, Teret SP. 2005. The City Planner’s Guide to the Obesity Epidemic: Zoning and Fast Food. Baltimore: The Center for Law and the Public’s Health. http://www.publichealthlaw.net/Zoning%20City%20Planners%20Guide.pdf. Accessed January 14, 2015.

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1300 L Street NW, Suite 975Washington, DC 20005(202) 265-5112www.leadershipforhealthycommunities.org

94 Mayor of Boston’s Press Office, 2012. “Mayor Menino and Ten Boston Hospitals Work Together to Reduce Consumption of Sugary Beverages Among Patients, Staff, and Visitors.” City of Boston, February.http://www.cityofboston.gov/news/default.aspx?id=5484. Accessed July 2013.

95 Sonnenberg L, Gelsomin E, Levy DE, Riis J, Barraclough S. 2013. “A Traffic Light Food Labeling Intervention Increases Consumer Awareness of Health and Healthy Choices at the Point-of-Purchase.” Preventive Medicine, 57(4):253-257.

96 Chaloupka, FJ, Wang YC, Powell LM, Andreyeva T, Chriqui JE and Rimkus LM. 2011. Estimating the Potential Impact of Sugar-Sweetened and Other Beverage Excise Taxes in Illinois. Chicago: Cook County Department of Public Health, October. http://www.cookcountypublichealth.org/files/pdf/Chaloupka_Report_PRF.pdf. Accessed July 2013.

97 Andreyeva T, Chaloupka FJ, Brownell K. 2011. “Estimating the Potential of Taxes on Sugar-Sweetened Beverages to Reduce Consumption and Generate Revenue.” Preventive Medicine, 52:413-416.

98 Friedman RR, Brownell KD. 2012. “Sugar-Sweetened Beverage Taxes: An Updated Policy Brief.” New Haven, CT: Rudd Center for Food Policy & Obesity.

99 Chaloupka FJ, Yurekli A and Fong GT. 2012. “Tobacco Taxes as a Tobacco Control Strategy.” Tobacco Control, 21:172-180 doi:10.1136/tobaccocontrol-2011-050417.

100 Dharmasena, S and Capps Jr O. 2012. “Intended and Unintended Consequences of a Proposed National Tax on Sugar-Sweetened Beverages to Combat the U.S. Obesity Crisis.” Health Economics, 21(6):669-694. Mytton O, Clarke D and Rayner M. 2012. “Taxing Unhealthy Food and Drinks to Improve Health.” British Medical Journal, 344:(2931). Smith TA, Lin BH and Lee JY. 2010. “Taxing Calorie Sweetened Beverages: Potential Effects on Beverage Consumption, Calorie Intake and Obesity.” USDA Economic Research Report, 100:1-23.

101 Mandaro L. “Nation’s First Soda Tax is Passed.” USA Today. November 5, 2014. http://www.usatoday.com/story/news/nation-now/2014/11/05/berkeley-passes-soda-tax/18521923/. Access January 20, 2015.