Policy Memo for Masters in Public Health

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Running head: BRIEFING BOOK

BRIEFING BOOK

Briefing Book

Renán Peña

SOPH 603: Assessment and Intervention: Wicked Problems in Public Health

Texas A&M University School of Public Health

November 15, 2018

Executive Summary

The briefing book addresses the impact of sugar consumption on health, and policies that could be implemented to reduce sugar intake. It is important to understand that increased sugar intake is detrimental to individual health due to the increased risk of type-2 diabetes, cardiovascular diseases, and mortality rates. Elisabeth and Merete (2018) determined that children’s self-control at lunch-time is determined by food-related lifestyle, parenting styles and parenting. While monitoring and control have been found to lower SSB consumption, overly strict practices may have adverse effects on eating behavior as it increases the consumption of unhealthy foods. Strict practices are more pronounced on younger children due to increased appeal of the restricted foods, leading to over-consumption in situations where restrictions are removed. On the other hand, Gortmaker, Wang, Long, Giles, Ward, Barrett, and Cradock (2015) address the cost-implications of implementing strategies that lower child obesity. They indicate that three studies projected that the cost of reducing childhood obesity results in increased cost savings. They also indicate that it is possible to reduce childhood obesity by the year 2025 in the United States. The researchers also indicate that the childhood obesity epidemic in the US affects all segments of society, but communities and health agencies have limited resources to address high rates of childhood obesity, necessitating the need to gain information on how best to invest those resources.

The commentary article by Medical Economics (2015) links sugary drinks to high death tolls associated with diabetes. The article indicates that sugary drinks may lead to an estimated 184,000 adult deaths each year worldwide. And that a reduction in the consumption of SSBs could potentially save tens of thousands of deaths annually. The second commentary article by Keller (1995) states that forward-thinking HFCS suppliers have implemented efficient infrastructure that has replaced sugar with sweeteners. This way, they can bring to market top-quality sweeteners at a price likely below the free-market price of refined cane or beet sugar. Therefore, large investments in HFCS have affected the production of SSBs, making it possible to produce drinks at low prices.

Briefing Book Sec 2 (Summary Sheets)

Peer-Reviewed Article #1

Elisabeth, L. M., & Merete, H. H. (2018). Soft drinks for lunch? self-control, intentions and social influences. British Food Journal, 120(8), 1735-1748. doi:http://dx.doi.org.ezproxy.library.tamu.edu/10.1108/BFJ-11-2017-0605

· Question: How much self-control do kids have during lunch at school?

· Methods: Multiple logistic regression was used to explore associations between the independent variables and SSB consumption. Psychometric evaluation of the self-control measure included factor analysis and internal consistency reliability. A web-based survey was conducted among 694 Norwegian high school students.

· Major Finding(s):

· Factor analysis resulted in two food-related self-control dimensions: resistance and avoidance.

· Multiple logistic regression showed that intentions was the strongest predictor of SSB consumption in the sample.

· Avoidance and descriptive peer norms appeared as weaker predictors.

· Food-related lifestyle, parenting styles and parenting practices have been found to be associated with SSB consumption in adolescents. Overly strict practices may have adverse effects on eating behavior by increasing the consumption of unhealthy foods. For younger children, it is suggested that this may be the result of an increased appeal of the restricted foods that lead to over-consumption in situations where restrictions are removed.

· Perceived peer behavior (i.e. descriptive norms) is also shown to be important, and in some cases even more strongly associated with adolescents’ intake than the actual behavior of the members of the peer group. Influence from peers seems as an important element for understanding adolescents’ SSB consumption.

· Key Facts:

· Options are available to the students

· Competing facilities with SSBs are a factor

· Availability and accessibility have consistently been identified as important predictors

· Positive association between intentions and SSB consumption during school lunch

· Feasibility/Scalability:

· The study only measured one county in Norway and did not take into account other parts of the country where behavior to SSBs may be different

· The study did not account for SSBs consumed outside of the school setting or time

· Key quote: “Today’s food environment with its ready availability of low-nutrient/high-energy foods and beverages calls not only for structural and social-environmental interventions to confront unhealthy temptations. Also personal tools like self-controlling strategies may be helpful to steer adolescents’ food and beverage consumption in a favourable direction—at least in contexts where structural and social-environmental interventions are not planned in the near future.”

Peer-Reviewed Article #2

Gortmaker, S. L., Wang, Y. C., Long, M. W., Giles, C. M., Ward, Z. J., Barrett, J. L., . . . Cradock, A. L. (2015). Three interventions that reduce childhood obesity are projected to save more than they cost to implement. Health Affairs, 34(11), 1932-65A. doi:http://dx.doi.org.ezproxy.library.tamu.edu/10.1377/hlthaff.2015.0631

· Question: Can we reduce childhood obesity by the year 2025 in the United States and how much will it cost?

· Methods: Evidence review and microsimulation modeling project concerning the cost effectiveness and population-level impact of seven interventions

· Major Finding(s):

· The childhood obesity epidemic in the US affects all segments of society.

· Communities and health agencies have limited resources to address high rates of childhood obesity and need to know how best to invest those resources.

· Reducing television viewing and other screen time leads to significant reductions in BMI and obesity prevalence, mainly via dietary changes.

· Key Facts:

· For adolescence an excess weight has accumulated for more than a decade, with an average imbalance of almost 200 extra kcal/day. The typical adult with a BMI greater than 35 consumes 500 kcal/day more than is needed to maintain a healthy body weight. Improving energy balance via improved diet and physical activity early in childhood thus requires much smaller changes than those needed once obesity is established in adolescence and adulthood.

· There is clear evidence of the effectiveness of reducing the intake of sugar sweetened beverages on reducing BMI and obesity prevalence.

· Three of the interventions studied were found to be cost-saving across the range.

· Policy Implications:

· The elimination of the tax deductibility of advertising costs for television ads seen by children and adolescents for nutritionally poor foods and beverages

· Restaurant menu calorie labeling modeled on the federal menu regulations to be implemented under the Affordable Care Act.

· Implementation of nutrition standards for federally reimbursable school meals sold through the National School Lunch.

· Implementation of nutrition standards for all foods and beverages sold in schools outside of reimbursable school meals.

· Improved early childhood education policies and practices.

· A nationwide fourfold increase in the use of adolescent bariatric surgery.

· Feasibility/Scalability: The reach of bariatric surgery, the smallest, was very limited, even assuming a fourfold increase in the number of adolescents who receive the procedure.

· Key quotes: “Setting nutrition standards for school meals would reach a very large population of children and have a substantial impact.”

· Key stakeholders: US policy makers, researchers, and nutrition and physical activity experts to provide advice concerning the selection of interventions, evaluation of data, analyses, and implementation and equity issues.

Commentary/ Opinion Article #1

Sugary drinks linked to high death toll for diabetes. (2015). Medical Economics, 92(15), 68. Retrieved from http://ezproxy.library.tamu.edu/login?url=https://search-proquest-com.ezproxy.library.tamu.edu/docview/1715905902?accountid=7082

· Question: Are sugary drinks linked to high death toll for diabetes?

· Major Finding(s):

· Sugary drinks may lead to an estimated 184,000 adult deaths each year worldwide

· Reduced consumption of SSBs could potentially save tens of thousands of deaths annually.

· There is a direct impact on diabetes and the obesity-related effects on cardiovascular disease CVD, diabetes and cancer.

· Key Facts:

· Researchers estimate that SSB consumption may have been responsible for approximately 133,000 deaths from diabetes, 45,000 deaths from cardiovascular disease (CVD), and 6,450 deaths from cancer.

· Estimates of consumption were made from 62 dietary surveys including 611,971 individuals, conducted between 1980 and 2010 across 51 countries, along with data on national availability of sugar in 187 countries and other information. This

· allowed capture of geographical, gender and age variation in consumption levels of SSBs in different populations.

· Key quotes (if relevant):

· “Many countries in the world have a significant number of deaths occurring from a single dietary factor, sugar-sweetened beverages. It should be a global priority to substantially reduce or eliminate SSBs from the diet.”

· “Sugar-sweetened beverages (SSB) are a single, modifiable component of diet that can impact preventable death/disability in adults in high, middle, and low-income countries, according to the study authors, indicating an urgent need for strong global prevention programs.”

Commentary/ Opinion Article #2

Keller, J. (1995). Sweet perspective. Beverage World, 114(1589), 4. Retrieved from http://ezproxy.library.tamu.edu/login?url=https://search-proquest-com.ezproxy.library.tamu.edu/docview/213322789?accountid=7082

· Question: How will the dissolution of sugar supports affect high-fructose corn syrup (HFCS) sweetened beverages?

· Major Finding(s):

· Free market production will lead to fair prices on all sugars

· The nations sugar policy and the shifts are likely to alter beverage production

· Forward-thinking HFCS suppliers, thanks to major continuing investments have in place an efficient infrastructure with which they can bring to market top-quality sweetener at a price likely below the free-market price of refined cane or beet sugar.

· Large investments in HFCS have affected the production of SSBs and how feasible it is to make cheaper drinks

· Key Facts:

· 75 percent of all North American HFCS production is dedicated to beverages

· There is a need for the ongoing presence of HFCS suppliers and their market-balancing choice.

· The 1974 switch from sucrose to HFCS was triggered by the volatility of a free market, when a wretched sugar beet crop in Europe pushed the global price of sucrose sky-high.

· Key quotes (if relevant):

· “Last November US voters sent our government a message: Dissolve yourself a little.”

· “The phase-out of the sugar supports isn’t official yet, and the timing is very far from being settled. But from here, it looks like a win-win-win situation. Now that’s sweet.”

· Key stakeholders (if relevant):

· Refined sugar producers

· HFCS producers

· Investors for both sucrose and HFCS

Briefing Book Sec 3 Wild Card

The Wild Card option is a recommendation for a policy to support healthy eating in the workplace.

Article 1

Thow, A. M., & Hawkes, C. (2014). Global sugar guidelines: An opportunity to strengthen nutrition policy. Public health nutrition, 17(10), 2151-2155. https://doi.org/10.1017/S1368980014001840

Question: What policies should be implemented to support individuals to consume less sugar?

Major Finding(s):

· Sugar intake should be reduced to less than 10% of total dietary intake

· Policies should create a supportive food environment

· Policies should increase healthy foods

· Policies should improve public awareness on healthy diets

Key Facts:

· Global sugar intake is higher than the recommended amount

· Adults’ intake of added sugar in proportion to dietary intake is 13-15%

Policy Implications:

· Reduction in sugar intake

· Development and implementation of a sugar policy

Key quotes: “These policies, combined with power structures in supply chains and the nature of international competition, mean that abundant sugar is readily available to consumers”.

Key stakeholders:

· Public and private procurement actors

· Governments

Article 2

Brambila-Macias, J., Shankar, B., Capacci, S., Mazzocchi, M., Perez-Cueto, F. J., Verbeke, W., & Traill, W. B. (2011). Policy interventions to promote healthy eating: a review of what works, what does not, and what is promising. Food and nutrition bulletin, 32(4), 365-375. https://doi.org/10.1177%2F156482651103200408

Question: What types of interventions should be implemented to address healthy eating?

Major Finding(s):

· Policy interventions should be implemented to reduce or ban unhealthy food advertising

· Policy interventions should enhance increased awareness on the impact of unhealthy eating

Key Facts: Diet quality falls short of conformity with World Health Organization dietary guidelines

Policy Implications:

Policies that target market environment are more effective in improving dietary intake.

Key quotes: “Measures to support informed choice have a mixed and limited record of success. On the other hand, measures to target the market environment are more intrusive but may be more effective.”

Key stakeholders:

· Consumers

· Policy makers

· Advocacy groups

Commentary Opinion Article 1

Panel, N. Z. B. G. (2014). POLICY BRIEF: options to reduce sugar sweetened beverage (SSB) consumption in New Zealand. Pac Health Dialog, 20(1), 98-102. Retrieved from http://fizz.org.nz/pdf/research/17%20Policy%20Brief.pdf

Abstract: The purpose of this document is to identify key policy recommendations to relevant settings that impact on the availability, marketing. price, and knowledge of SSBs and ultimately the consumption of SSBs in New Zealand, particularly in youth. These recommendations will provide achievable goals to various stakeholders and settings of infl uence, aiming to reduce SSBs intake. The ideal outcome is that water and milk (unfl avoured) become preferred beverage options for New Zealand children and adults. These goals align to the vision articulated by the advocacy group ‘FIZZ’ to achieve a Sugary Drink Free New Zealand by 2025.1,2 This means that SSBs should be only rarely consumed, and comprise less than 5% of total population beverage intake. Addressing SSBs in particular is an important step to addressing New Zealand’s obesity epidemic, especially among children.

Question: What are some of the recommendations to reduce sugar consumption?

Major Finding(s):

· Government should implement pricing options, restrictions, and regulations that impact availability and access of SSB

· Implement social marketing campaigns supporting healthy beverage choices and discourage unhealthy beverage choices

· Development of organizational healthy beverage policies promoting SSB-free products

Key Facts:

· There is evidence that the reduction of SSB reduces the likelihood of developing health conditions

· Consumption of SSB causes unhealthy weight gain, gout, dental diseases, and type-2 diabetes

· Government leadership at local and national levels is needed to foster meaningful change

Policy Implications:

· SSB should become a health priority for action

· Reduction in the consumption of SSB

· Reduction in incidents involving cardiovascular diseases

Key quotes: “Leadership and action from governments, in terms of programs and policies, to promote and create healthier food environments are urgently required. A number of plausible policy options that the government can consider to influence the SSB environment include pricing options, restrictions, regulation and policies that impact on availability and access as well as marketing, sponsorship and the media.”

Key stakeholders:

· Policymakers

· Governments

· Non-governmental organizations

· Advocacy groups

Commentary Opinion Article 2

Gortmaker, S. L., Swinburn, B. A., Levy, D., Carter, R., Mabry, P. L., Finegood, D. T., ... & Moodie, M. L. (2011). Changing the future of obesity: science, policy, and action. The Lancet, 378(9793), 838-847.

Question:

What interventions should be employed to reduce sugar intake?

Major Finding(s):

· A coordinated approach by governments, private sector, civil society, and international organizations is needed to address increased sugar intake

· Priority actions should include increased funding for prevention programs

Key Facts:

Studies have correlated increased energy intake with weight change

Policy implications

Increased investments in prevention programs and monitoring will improve accuracy of evaluations

Key quotes:

“The integration of actions within existing systems into both health and non-health sectors (trade, agriculture, transport, urban planning, and development) can greatly increase the influence and sustainability of policies.”

Key stakeholders:

· Governments

· Private sector

· Civil society

· International organization

Compendium of the Articles

Anonymous (2015). Sugary drinks linked to high death toll for diabetes. Medical Economics, 92(15), 68. Retrieved from http://ezproxy.library.tamu.edu/login?url=https://search-proquest-com.ezproxy.library.tamu.edu/docview/1715905902?accountid=7082

Thow, A. M., & Hawkes, C. (2014). Global sugar guidelines: An opportunity to strengthen nutrition policy. Public health nutrition, 17(10), 2151-2155. https://doi.org/10.1017/S1368980014001840

Brambila-Macias, J., Shankar, B., Capacci, S., Mazzocchi, M., Perez-Cueto, F. J., Verbeke, W., & Traill, W. B. (2011). Policy interventions to promote healthy eating: a review of what works, what does not, and what is promising. Food and nutrition bulletin, 32(4), 365-375. https://doi.org/10.1177%2F156482651103200408

Panel, N. Z. B. G. (2014). POLICY BRIEF: options to reduce sugar sweetened beverage (SSB) consumption in New Zealand. Pac Health Dialog, 20(1), 98-102. Retrieved from http://fizz.org.nz/pdf/research/17%20Policy%20Brief.pdf

Gortmaker, S. L., Swinburn, B. A., Levy, D., Carter, R., Mabry, P. L., Finegood, D. T., ... & Moodie, M. L. (2011). Changing the future of obesity: science, policy, and action. The Lancet, 378(9793), 838-847.