From Access to Taxes:
Strategies for Reducing Sugar
Consumption in the U.S
Jim Krieger, MD, MPH
Executive Director
Healthy Food America
www.nwcphp.org/hot-topics
Epidemics of diabetes and obesity
Prevalence of Obesity - US Adults 1960 - 2010
Prevalence of Diagnosed Diabetes - US Adults 1980 2011
40
7
35
6
30
5
25
Percent
20
15
10
4
3
2
5
1
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2010
2007
2004
2001
1998
1995
1992
1989
1986
0
1983
2009-2010
2007-2008
2005-2006
2003-2004
2001-2002
1999-2000
1988-1994
1976-1980
1971-1974
1960-1962
0
1980
Percent
1 out of 3 children
born in the year 2000
will develop diabetes
What is driving the epidemics?
The role of energy balance
Not enough calories OUT
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Too many calories IN
Energy gap is 30-175
calories per day
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Calories in
US food
supply
Diet the
primary driver –
what we eat
matters more than
how much we
move for obesity
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278
calories
Reported
physical
activity by US
adults
Type of calorie matters
250
600
200
500
400
150
300
100
200
50
100
0
1970
1974
1978
1982
1986
1990
1994
1998
2002
2006
2010
0
Total fat grams
Percent
Prevalence of Obesity
US Adults, 1960-2010
Kilocalories
Grams
Type of calories in the
US food supply, 1970-2010
40
35
30
25
20
15
10
5
0
Saturated fat grams
Carbohydrates kcals
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But not only too many calories:
A calorie is not a calorie
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We are consuming too much added sugar
Per Capita Availability of Caloric Sweeteners
Compared With Recommendations
Teaspoons of Sweetener Per Day
30
25
Current consumption
20
15
10
WHO & US Dietary Guideline Recommendations: 12 tsp/day
AHA Recommendation for men 9 tsp/day
AHA Recommendation for women 6 tsp/day
5
0
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23 teaspoons
per day
Children consume
50-70% more
added sugars than
Dietary Guidelines
for American
recommends
DGA 2015:
“Healthy eating
patterns limit added
sugars to less than
10 percent of
calories per day.”
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The US leads the world in sugar consumption
800
700
600
500
400
300
200
100
0
Calories from sugar
Calories from high fructose corn syrup
Source: USDA-ERS, Conadesuca, OECD, Credit Suisse Research, via The Conversable Economist
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Focus on sugary drinks
o
o
o
o
o
o
o
Primary source of added sugar in U.S. diet
Major source of added calories fueling the obesity epidemic
Consumption higher among low income and minority populations
Cause obesity, diabetes, dental decay, liver, and heart disease
Do not affect appetite
Heavily marketed (and youth and minorities targeted)
No nutritional benefits
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Almost half of
added sugars
comes from
sugary drinks
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Source: Dietary Guidelines for Americans, 2015-2020,
How much sugar is in that drink:
QUIZ TIME!
16 oz
20 oz
32 oz
11 oz
11 tsp
15 tsp
13 tsp
8 tsp
And for a bonus:
 What is the recommended daily limit for sugar intake?
<10% daily calories, ~12 tsp/day
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Dramatic increase in sugary drink availability
45
40
30
25
Availability
triple what it
was 60 years
ago
Regular soft drinks
20
6
15
5
Juice drinks
Sports drinks
4
10
3
2
5
1
0
0
1954
1956
1958
1960
1962
1964
1966
1968
1970
1972
1974
1976
1978
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
2010
2012
2014
Gallons of Soft Drink
35
Sources: (1954-2003): Beverages Table. United States Department of Agriculture, Economic Research Service Food Availability (Per Capita) Data System Website.
Updated February 1, 2015. Accessed September 9, 2015. (2004-2014): Beverage Digest annual estimates; Caloric CSDs based on estimate that 70% of CSDs are caloric and 30% are non-caloric/diet.
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One or more sugary drink per day
US Adults, 2013
Sugary drink
consumption
varies by race
and income
• 29% of all adults
report drinking
one or more
sugary beverages
per day
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Racial Disparities
40%
36%
27%
Black, nonHispanic
Hispanic
21%
White, non- Other, nonHispanic
Hispanic
Income Disparities
38%
33%
26%
18%
Even the youngest children consume too much
31% of toddlers age 12-23
months consume sugary
drinks on any given day.
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Sugary drinks cause chronic diseases
2 sodas/day for just 2 weeks:
↑ LDL cholesterol & triglycerides by 20%.
2 sodas/day for 6 months:
↑ Visceral fat, fatty liver disease.
1 soda/day:
↑ Risk of overweight/obesity by 55% (children).
↑ Risk of diabetes by 26%.
↑ Risk of dying from heart disease by almost 1/3.
↑ Risk of stroke by 22%.
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How do we reduce sugar consumption?
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↓ Affordability
↓ Acceptability
↓ Appeal
↓ Availability
Polling Question #1
What strategies have you or your organizations tried for
reducing sugar consumption?
Affordability
Acceptability
Appeal
Availability
None
Affordability
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Sugary drink tax
o Reduce consumption 20% at a two-cents per ounce
o Reduce disease
• Diabetes: 3.4% decrease in new cases over 10 years
• Obesity:
• 1% decrease (adults)
• 1.4% decrease (children)
o Increase awareness about adverse health effects
o Generate revenue to support community health and well-being
o Reduce national health care costs by $23 billion over 10 years
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BERKELEY SODA TAX
yes
no
24%
76%
SAN FRANCISCO SODA
TAX
yes
45%
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no
55%
2015: Berkeley and San Francisco
• Penny per ounce
• Tax is showing up on shelf price
• Raising $1.5 million per year
• Supporting chronic disease prevention
2016: Philadelphia
A Watershed
• 1.5 cents per ounce
• Projected to raise $91M per year
• Supports popular programs: pre-K,
community centers and schools,
parks
• Framed as revenue tool, not
health measure
• Council vote (not ballot)
• Beware lawsuit and preemption
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Industry
response
• San Francisco - 33:1
›
Opposition: $9.2M
›
Supporters: $277K
• Berkeley - nearly 5:1
›
›
Opposition: $2.4M
Supporters: $521K
› Philadelphia – 3:1
› Opposition: $5+ M
› Supporters: $1.4 M
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Mexico
o Passed a 1 peso per liter tax in 2014 (10%)
o Consumption down 12%
o Raised $1.2 billion per year
o Revenues support potable water
o Industry attempt to rollback failed
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Where will the next tax happen?
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Sugary drink excise tax efforts
in the US since 2009
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Current activity: Albany,
Boulder, Oakland, Philly, SF,
AL,IL
Sugar tax
o Types of taxes
• Cap and trade
• Excise
Norway: excise tax on
high sugar foods (36
cents per pound) and
beverages (1 cent per
ounce)
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Hungary: excise
tax on sugary
foods (16 cents
per pound)
Acceptability
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Health information at point of purchase
Consumers lack information on the
health effects of sugary drinks.
o Require health warnings on sugary
drinks
o Require health warnings on ads
o Post health information signs on
shelves where sugary drinks are sold
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San Francisco
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Baltimore
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Nutrition facts panel
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Appeal
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Address marketing and promotion
o Federal regulatory action unlikely
(IOM)
o Restrict advertising to children
• Media (TV, digital)
• Schools and other settings
• Kids Meals
o Restrict price promotions
o Counter-marketing
o Eliminate tax deduction for
advertising
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Cubes
per year
consume
d: more
than
weight of
5 year old
Increasing awareness
of sugary drinks
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Availability
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Kids meals
A third of all US children and
adolescents aged 2–19 consume fast
food on a given day.
o Ban soda as default beverage
option (Davis, Stockton) or ban
completely
o Nutritional standards for kids meals
o Some chains are removing soda:
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• Applebee’s
• Wendy’s
• IHOP
• Subway
• Dairy Queen
• Chipotle
• Burger King
• Panera
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Portion sizes
Larger portion sizes lead to
greater consumption.
o Limit portion sizes of drinks served
in restaurants
o Limit portion sizes of bottled SSBs
sold in stores
o NYC regulation rejected by courts
based on lack of Board of Health
authority
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Government purchasing
o Vending
o Cafeterias
o Government programs:
• Parks and Recreation
Sites
• Child care and
before/after school
programs
• Senior Centers
• City hospitals, jails
o Government contracts
Washington Executive Order
o All state executive agencies adopt and begin
to implement a food and beverage service
policy for employees and students,
custodial populations, and residents
o By December 31, 2016, each agency’s policy
fully implemented
o All state food venues, including vending
machines, cafeterias, on-site retail
establishments, and meetings or events
meet healthy food standards based on the
2010 Dietary Guidelines for Americans
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Schools
No sugary drinks in schools
Cafeteria choice architecture
o USDA bans full sugar drinks during
class hours for elementary and
middle schools
o Allows drinks with <40 cal/8 oz in
high schools
o Ban food advertising in schools
o Limit added sugars in school meals
o Work remains:
• Assure implementation
• Seek total elimination from schools
• Address in-school marketing
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Child care
• Distributing nutrition
information
• Licensing and regulation
• Offering technical
assistance to implement
healthy practices and
policies
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Hospitals
o In 2006, 99% of hospital cafeterias sold soda
o Partnership for a Healthier America:
150 hospitals now serve healthier drinks
o Healthier Hospitals: 500 hospitals ($20
billion in purchasing power) committed to
healthier foods
o In King County, 9 hospitals pledged to
increase healthy beverage purchases by 20%
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Supermarkets: Checkout aisles
60% of checkout beverage
offerings are soda and
other sugary drinks.
o Limit presence of sugary
drinks (and other less
healthy foods) in checkout
aisles
o Aldi (1500 stores) is first
large US chain to do so
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Bridging the Gap: Availability of Healthy Food Products at Check-out Nationwide, 2010–2012
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Working with
industry
• Appeal: Promote
healthier
beverages:
› Endcaps and
displays
› Shelf location
› Checkout aisles
› Advertising
• Affordability: Price
healthier beverages
lower
• Availability: Lower
sugar content
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UK
o Tesco decreasing the sugar content of house
brand soft drinks
o Pulling all kids juice drinks with added sugar
from shelves
Boston
o Chains pledge to reduce promotion and
marketing of sugary drinks
Polling Question #2
What strategy would you be interested in trying in your
organization or region?
Please type your answer into the chat box.
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