Will NYC's New Mayor Follow Through on Soda Limits?

Evidence-Based Diabetes Management, December 2013, Volume 19, Issue SP11

With Science Reaching Consensus on Health Effects of Sugary Drinks, Talk of Portion Caps and Taxes Gains Steam Globally

Little overlaps in the world views of New York City’s outgoing and incoming mayors, but on this they agree: The Big Apple would be better off without the Big Gulp.

Mayor Michael Bloomberg, who leaves office December 31, 2013, was as zealous about pushing New Yorkers to quit smoking and lose weight as he was about stop-and-frisk policing. In his third term, he pressed the city’s Board of Health to make New York City the only place on the planet to cap sugar-sweetened beverages at servings of no more than 16 ounces, defined as containing more than 25 calories of sugar in 8 ounces.1

Though pilloried by critics and parodied on late-night TV, Bloomberg’s so-called “soda ban” is supported by a growing body of evidence that sugarsweetened beverages, or SSBs, not only contribute to childhood obesity but also to cardiovascular disease. In March 2013, a lower court ruling reversed the portion cap based on questions about the Board of Health’s authority and uneven enforcement—for starters, New York State regulates 7-Eleven, so the “Big Gulp” would remain. But so far no court has questioned the scientific foundation of whether a portion cap was good for public health.2

Perhaps for that reason, on October 17, 2013, Bloomberg vowed to move on to the New York State Court of Appeals, stating, “I’ve got to defend my children and yours, and do what’s right to save lives. Obesity kills. There’s no question it kills.”2

Sugar-sweetened beverages, typically soda, are sold in “large” portions that start at 20 ounces and range up to 64 ounces. A coalition of small retailers, labor unions and the state’s beverage industry sued, successfully claiming the Board of Health overstepped its authority when it passed the Sugary Drinks Portion Cap Rule. The Court of Appeals announced it will take up the case early next year, after Bloomberg’s successor, Mayor-elect Bill de Blasio, takes office.

De Blasio’s position on the portion ban has taken an interesting route. As the city’s public advocate and later as a mayoral candidate, he found his political base in neighborhoods where police stop and frisk the most but also where sales of sugary drinks are brisk and rates of obesity and diabetes are highest.

The “soda ban’’ was not popular with the de Blasio base, but he praised Bloomberg and gave a full-throated endorsement of the cap when asked during the campaign.3

“I’m not ever afraid to disagree with Mayor Bloomberg when I think he’s wrong, but when I think he’s right, my job as public advocate has been to support policies that have been good for the people; and I think as a parent, especially I feel we have been losing the war against obesity,” he said.3

“We have to, of course, look at the specifics with our own lawyers to handle the mechanics, but there’s no question I want to see this rule go through,” de Blasio continued. Published reports, however, hint that de Blasio may take a different path to achieve the same public health goal; his transition team did not return multiple calls and e-mails from Evidence-Based Diabetes Management.

De Blasio’s support for the portion cap rule was not the first time he worked with Bloomberg on an obesity initiative. In 2010, as public advocate, he supported Bloomberg’s effort to gain US Department of Agriculture approval of a trial program to remove SSBs from the list of foods approved for purchase with food stamps, essentially categorizing the drinks with cigarettes and alcohol.4

The petition was the target of intense lobbying by Bloomberg and the beverage industry. De Blasio was one of the first elected officials to support the controversial proposal, which was opposed by some of his political supporters. The Department of Agriculture rejected the pilot program in 2011, arguing it was “too large and complex.’’5

“By subsidizing the purchase of soda with food stamps, we’ve been unwittingly stacking the deck in favor of these unhealthy beverages,” de Blasio was quoted saying at the time. “This pilot program could help even the odds for healthier foods.”

The Case Against Sugary Drinks

De Blasio’s policy instincts align with a swelling body of research that cheap, jumbo-sized sugar-sweetened beverages are more responsible for the global obesity epidemic than any other factor.6 The American Heart Association (AHA), in a 2009 scientific statement, linked the “pandemic of obesity and cardiovascular disease’’ to a parallel increase in sugar consumption, calling sugar-sweetened beverages “the primary source of added sugars in Americans’ diets.”

The AHA found that from 1970 to 2005 US per capita sugar consumption increased 19%, adding 76 calories per day with calories from sugar totaling 355. It recommended drastically reducing sugar consumption to “a prudent upper limit’’ of 100 calories per day for women and 150 for men.7

The case against consuming too much sugar has mounted since the AHA statement. Research published in 2010 in the Journal of the American Medical Association reported “a statistically significant correlation between dietary added sugars and blood lipid levels among US adults.’’ Nonalcoholic fatty liver disease (NAFLD) prevalence has more than doubled over the past 20 years and currently affects nearly 11% of adolescents and one-half of obese males.8

Adolescents who increase sugar consumption increase their cardiovascular disease risk,9 while a study of 224 overweight and obese adolescents children aged 2 through 17 years found substituting water for all SSBs trimmed 235 calories per day and concluded that their average daily consumption of 1.7 servings of sugar-sweetened beverages “may cause excessive weight gain.”10 Adolescents from that study group who participated in an intervention that reduced their consumption of SSBs to 0 over a year achieved “significant’’ weight reduction compared with a control group.10

Research published in 2009 and 2011 by Kimber Stanhope, PhD, RD, of the Department of Molecular Biosciences at the University of California, Davis, and her colleagues demonstrated that routine consumption of fructose-sweetened drinks by older, overweight adults soon caused increased weight gain around the middle, and worsened cardiovascular risk factors and the ability to utilize insulin properly.

The 2009 study,11 published in the Journal of Clinical Investigation, showed older overweight adults who consumed fructose showed increased visceral adiposity, increased cardiovascular risk factors, and increased insulin resistance. Stanhope reported in the Journal of Clinical Endocrinology and Metabolism in 2011 that healthy young adults consuming fructose- and high-fructose corn syrup-sweetened beverages for 2 weeks also had worsened cardiovascular risk factors.12

“My study shows young healthy subjects had increases of LDL of 20% in 2 weeks when they consumed 3 servings a day. Somebody should be looking at that and blinking,’’ Stanhope said. “These are normal metabolic pathways we’ve known about for years. It makes sense what fructose is doing.’’

Targeting Sugary Drinks Through Policy

Stanhope has been among the leaders in the scientific community nudging policy makers to catch up to what the data show. At her presentation in June at the 73rd Scientific Sessions of the American Diabetes Association in Chicago, she asked the rhetorically whether the panel creating the 2015 Dietary Guidelines for Americans needed to wait for conclusive results before educating the public to stop drinking so much sugar.13 Also on the dais was Y. Claire Wang, MD, ScD assistant professor of health policy and management at the Mailman School of Public Health at Columbia University, whose work formed the scientific foundation for Bloomberg’s initiative. Along with her data, Wang shared visuals of how “small,” “medium,” and “large” soda cups have increased in size over the past generation.14

Stanhope presented her research to the California Senate Health Committee when it was considering a tax on SSB in 2013 and more recently to the Mexican Congress, which has passed a national tax on SSBs and on fast foods high in salt, sugar, and saturated fat to confront that nation’s obesity epidemic.15 Mexico has surpassed the United States as having the highest adult obesity rate in the world.16

“There were large newspaper ads I saw in Mexico saying sugar has no ill effects, that fructose has no ill effects, it’s all about calories, but when I separate my data into who gained weight and who didn’t, even those who didn’t gain weight have higher risk factors for cardiovascular disease,’’ Stanhope said. “We have a lot of evidence, but we will continue to work hard at generating more until the adverse effects of excessive sugar consumption are inarguable, and until we know just how much sugar can be consumed safely each day.

Meanwhile, the safe advice for everyone, young and old, is to eat as little processed, high-sugar food as possible.” Ian McLaughlin, senior staff attorney and program director working on childhood obesity and tobacco control with ChangeLab Solutions, a nonprofit in Oakland, California, that has published a Sugar-Sweetened Beverages Playbook17 listing 10 strategies, typically starting with public education campaigns and gradually restricting access to SSBs. Taxes and capping portion sizes are listed as the most challenging steps in the playbook. On October 31, 2013 the United Kingdom’s Academy of Medical Royal Colleges proposed a 20% soda tax to curb obesity, especially among those under age 30 years.18

“Sugar, in my opinion, is on the same trajectory as tobacco, but it’s more complex and at an earlier place in the process,’’ McLaughlin said. “These beverages are truly ubiquitous, including in places without good tap water. A lot of communities grappling with this need a framework for thinking this through. The playbook tells them what other communities are doing. Most jurisdictions are working on public awareness, removing vending machines from schools, that sort of thing, while more progressive communities are looking at the retail component, taxes, or the portion cap size.’’

Very few places, but including New York State, have attempted to enact taxes stiff enough to discourage SSB consumption. With the exception of a bill that quickly vanished in a subcommittee of the Oregon Legislature a few years ago, McLaughlin knows of no place aside from New York City that has tried to limit portion sizes.

The portion cap rule, if the court allows it, appears to be the second choice of Bloomberg and others in New York who worked for an SSB tax, said Assemblyman Felix W. Ortiz, D-Brooklyn.

Ortiz, since joining the Assembly in 1994, has succeeded with bills to ban vending machines from schools, create calorie labeling in restaurants, and enhance school meal programs with local produce. But he has thus far been stymied in his efforts to pass a tax on sugary drinks. He came closest in 2009 when then-governor David Patterson included a 1-cent-per-ounce tax in his proposed budget. Patterson withdrew support following a 2010 lobbying blitz by the state beverage industry.19

Ortiz reasoned that when the tax plan failed, Bloomberg turned to the city’s Board of Health—composed solely of his appointees—with the confidence that he would repeat his successful ban of trans fats from New York City restaurants, which was enacted in 2006.20 Bloomberg asserted that the Board of Health had the authority to cap SSB portions. “The mayor knew he had the power to do it, that he didn’t need the state (legislature) or the city council, so he did it,’’ Ortiz said.

Wang estimated after the portion cap rule was proposed that it would “likely to result in a modest reduction in excess calories from SSBs, especially among young adults and children who are overweight.’’21 Expectations were greater for the failed soda tax. A 2010 study by Wang estimated a statewide tax over a decade could have avoided 37,400 cases of diabetes, saving $1.2 billion in healthcare costs and resulting in 145,000 fewer adults becoming obese, saving $2.1 billion in medical expenditures. Wang’s subsequent study published in Health Affairs estimated a nationwide tax would generate $17 billion in medical savings over the same period.22

If big numbers are not convincing, the incoming mayor expresses the fight in personal terms. He described the need to take on soda portions this way: “Right now, it’s hard to be a parent in New York City. I have 2 teenagers, I’m surviving the experience, and (my wife) Chirlane and I spent a lot of time working to make sure (our children) Chiara and Dante are healthy. That means encouraging nutrition; that means encouraging exercise. But, you know, it takes a lot of energy to keep on top of kids and make sure they do the right thing.

“Unfortunately, as parents, it feels like every day we’re fighting an enemy, and that is the growing availability of bigger and bigger sugary drinks.”3References

1. NYC Health. Sugary drink portion cap rule: fact vs. fiction. http://www.nyc.gov/html/doh/downloads/pdf/cdp/sugary-drink-facts.pdf. Accessed November 8, 2013.

2. Barkan R. DeBlasio vows to continue Bloomberg’s Soda Cup Fight. Politicker. October 18, 2013. http://politicker.com/2013/10/deblasio-will-continue-to-wage-bloombergs-sodacup-fight/ Accessed November 16, 2013.

3. Grynbaum M. Court halts ban on large sodas in New York City. The New York Times. March 12, 2013: A1.

4. Saul MH. Soda ban gets key backer. The Wall Street Journal. December 3, 2010. http://online.wsj.com/news/articles/SB10001424052748703377504575651251696268376. Accessed Nov. 15, 2013

5. McGeehan P. US rejects mayor’s plan to ban use of food stamps to buy soda. The New York Times. August 19, 2011:A15

6. Malik VS, Schulze MB, Hu FB. Intake of sugar-sweetened beverages and weight gain: a systematic review. Am J Clin Nutr. 2006;84(2)274-288.

7. Johnson, RK, Appel LJ, Brands, M, et al. Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association [published online August 24, 2009]. Circ J Am Heart Assoc. 2009:120;1011-1020.

8. Welsh JA, Karpen S, Vos MB. Increasing prevalence of nonalcoholic fatty liver disease among United States adolescents, 1988-1994 to 2007-2010 [published online October 17, 2012]. J Pediatr. 2013;162(3):496-500.e1.

9. Welsh, JA, Sharma A, Cunningham SA, Vos MB. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents [published online January 25, 2011]. Circ J Am Heart Assoc. 2011;123(3):249-57.

10. Ebbeling, CB, Feldman HA, Chomitz VR, et al. A randomized trial of sugar-sweetened beverages and adolescent body weight [published online September 21, 2012]. N Engl J Med 2012;367(15):1407-16.

11. Stanhope, KL, Schwarz JM, Keim NL, et al. Consuming fructose-sweetened, not glucosesweetened, beverages increases visceral adiposity and lips and decreases insulin sensitivity in overweight/obese humans. J Clin Invest. 2009;119(5):1322-1334.

12. Stanhope, KL, Bremer AA, Medici V, et al. Consumption of fructose and high-fructose corn syrup increases postprandial triglycerides, LDL-cholesterol, and apolipoprotein-B in young men and women [published online August 17, 2011]. Journal of Endocrin Metab. 2011;961(10:E1596-E1605.)

13. Stanhope, KL, Schwarz, JM, Havel PJ. Adverse metabolic effects of dietary fructose: results from ther recent epidemiological, clinical and mechanistic studies. Curr Opin Lipidol. 2013;24(3):198-206.

14. Wang YC. Symposium Speaker, Dietary Sweeteners—Research, Recommendations and the Real World. 73rd Scientific Sessions of the American Diabetes Association; June 23, 2013; Chicago, IL.

15. Boseley S. Mexico to tackle obesity with taxes on junk food and sugary drinks. The Guardian, November 1, 2013. http://www.theguardian.com/world/2013/nov/01/mexicoobesity-taxes-junk-food-sugary-drinks-exercise. Accessed November 16, 2013.

16. Food and Agriculture Organization of the United Nations. The state of food and agriculture:food systems for better nutrition. July 2013. http://www.fao.org/docrep/018/i3300e/i3300e.pdf Accessed November 20, 2013.

17. ChangeLab Solutions. Sugar-Sweetened Beverages Playbook, ChangeLab Solutions website, October 2013. http://changelabsolutions.org/publications/SSB-playbook Accessed November 16, 2013.

18. Bennett S. Soda Tax of 20% may cut UK obesity rate by 180,000. Bloomberg, October 31, 2013. http://www.bloomberg.com/news/2013-10-31/soda-tax-of-20-may-cutu-k-obesity-rate-by-180-000.html. Accessed November 18, 2013.

19. Hartocolis A. Failure of state soda tax proposal reflects power of anti-tax message. The New York Times. July 3, 2010: A14.

20. New York Board of Health votes to phase out artificial trans fat from New York City’s restaurants [press release]. New York City: New York City Board of Health, December 5, 2006. http://www.nyc.gov/html/doh/html/pr2006/pr114-06.shtml Accessed November 17, 2013.

21. Wang, YC, Vine SM. Caloric effect of a 16-ounce (473-mL) portion-size cap on sugar-sweetened beverages served in restaurants [published online June 12, 2013] Am J Clin Nutr.

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22. Wang, YC, Coxson P, Shen, YM, Goldman L, Bibbins-Domingo, K. A penny-per-ounce tax on sugar-sweetened beverages would cut health and cost burdens of diabetes. Health Aff.

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