From the Journals

AAP, AHA push for policies limiting children’s sugary beverage consumption

Make counseling on healthy eating and exercise a priority

Pediatricians daily bear witness to the impact of poor nutrition on the health and quality of life of children. Healthy eating and drinking has long been an expected domain of conversation with children, adolescents and their families. In recent years, counseling regarding the consumption of added sugars, especially those in sugar-sweetened beverages (SSB), has gained traction. Pediatricians are aware of the health risks associated with over-consumption of SSB and that these risks, and consumption of sugary drinks, are more prevalent among the most vulnerable of children, including minorities and those living in low-income communities.

Dr. Melinda Clark

The general public generally understands that water and milk are the healthiest beverages for children but often underestimate SSB consumption, its effect on overall diet, and the magnitude of its potential ill effects on health. Pediatricians can consistently advocate for drinking of water and unflavored milk and encourage parents to keep juice, juice drinks, flavored milk, soda, and sports drinks out of the home.

Primary care pediatricians face many demands that compete for time and attention, and time spent counseling on healthy eating and exercise needs to continue to be a priority. AAP-supported initiatives, such as the 5-3-2-1-0 rule – five vegetables and fruits per day, three structured meals, 2 hours or less of screen time, 1 hour or more of physical activity and zero sugary drinks most days – provide simple, clear messaging about limiting of sugary drinks. We should promote drinking of water as first choice, including during sports activities.

Messaging with community partners and on social media maximizes the impact of these important messages. The new AAP guideline “Public Policies to Reduce Sugary Drink Consumption in Children and Adolescents” also advocates for decreasing sugary drink marketing to children and adolescents. Pediatricians are trusted, credible voices who are well-positioned to advocate for an ad-free childhood, including SSB ads.

Melinda Clark, MD, is an associate professor of pediatrics at the Albany (N.Y.) Medical Center, and a MDedge Pediatrics editorial advisory board member. Dr. Clark had no disclosures.



Physicians should actively advocate for policies that will reduce children’s consumption of sugar-sweetened beverages and subsequently reduce their risk of obesity, type 2 diabetes and other chronic diseases, urges a new policy statement from the American Academy of Pediatrics and the American Heart Association.

American Heart Association

As “the leading source of added sugars in the U.S. diet,” sugary drinks “provide little to no nutritional value, are high in energy density, and do little to increase feelings of satiety,” wrote Natalie D. Muth, MD, MPH, of the University of California, Los Angeles, and the Children’s Primary Care Medical Group in Carlsbad, Calif., and her associates from the AAP’s Section on Obesity, the AAP’s Committee on Nutrition, and the American Heart Association.

Added sugars include sucrose, glucose, high-fructose corn syrup and processed fruit juice (but not naturally occurring fructose or lactose) that are added as sweeteners to food and drink products. In addition to contributing to childhood obesity, consuming drinks with added sugars increases children’s risk for “dental decay, cardiovascular disease, hypertension, dyslipidemia, insulin resistance, type 2 diabetes mellitus, fatty liver disease and all-cause mortality,” the statement noted.

Although less than 10% of individuals’ total calories should come from added sugars, according to the 2015–2020 Dietary Guidelines for Americans, added sugars make up an estimated 17% of U.S. children’s and teens’ average total caloric intake, and sugary drinks comprise almost half of this excess sugar, the statement noted. Consumption is higher and therefore more harmful in several subgroups, particularly those from minority and economically disadvantaged communities.

Previous AAP policy statements have urged doctors to encourage children and teens to drink water instead of high-calorie drinks, such as fruit juice, energy drinks and high-carbohydrate “sports drinks.” But this statement takes a page from success with tobacco control measures and focuses on the need for policy changes at local, state, and federal levels to help to reduce children’s intake of sugary drinks.

The statement makes six major recommendations:

• Excise tax: The AAP and AHA support the use of excise taxes or other means of increasing the cost of sugar-sweetened beverages – alongside an educational campaign to explain the rationale – and apportioning some of the subsequent revenue to addressing health and socioeconomic disparities.

Evidence shows how tobacco and alcohol consumption declined as their prices rose from taxes, and several places that have already implemented a sugary beverage tax have seen similar declines in consumption. Research models suggest an excise tax would potentially prevent 575,000 cases of childhood obesity.

• Reducing advertising/marketing: Research shows that teens, especially low-income and minority teens, are exposed to high amounts of advertising for soft drinks, fruit drinks, energy drinks, and sports drinks. Though such advertising cannot be outright banned without violating free speech, policies can disincentivize such marketing, such as “eliminating the advertising subsidy for nutritionally poor foods and beverages marketed to children” and not allowing in-school marketing.

• Improve existing nutritional assistance programs: WIC, the Child and Adult Care Food Program, school breakfast and lunch programs, and the Supplemental Nutrition Assistance Program (SNAP) vary in how well they discourage sugary drink consumption and can be improved through legislative changes.

• Consumer risk information: The AAP and AHA promote use of clear nutrition labels and menu labeling that explain the sugar content and risks of products, “including warning labels of the health harms of consumption of added sugars” not unlike those on cigarette packages.

• Changing the default: Physicians should advocate for policies that reduce access to sugary drinks and prioritize access to water and similarly healthier options.

• Norm-changing medical industry: Hospitals should implement policies that reduce consumption and/or access to sugary beverages, such as higher prices, less availability and risk-related labeling.

Pediatricians should continue to advise families about the risks of consuming added sugars, the substantial contribution that sugary drinks make to excess sugars in one’s diet, and the need to replace sugar-sweetened beverages with drinking water. Yet pediatricians can go beyond individual recommendations by advocating “for policy change through school boards, school health councils, hospital and medical group boards and committees, outreach to elected representatives and public comment opportunities.”

The statement used no external funding, and the authors had no disclosures or conflicts of interest.

SOURCE: Muth ND et al. Pediatrics. 2019;143(4):e20190282. doi: 10.1542/peds.2019-0282

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