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Sugar sweetened beverages (SSB) constitute a large percentage of energy consumed by youth. This paper reviews the literature on school nutrition policies and price interventions directed at youth SSB consumption. In addition to considering the direct effect of policies on SSB consumption, we provide an overview of the literature on how SSB consumption affects total energy intake (TEI) and BMI, as well as on how TEI affects BMI. By considering each of these links, we attempted to gauge the effect of policies directed at SSB consumption, as well as highlight areas that merit future research. We found that school nutrition and price policies reduce SSB consumption and that reduced SSB consumption is associated with a reduction in energy intake that can influence BMI. Policies directed at SSB consumption can play an important role in reducing youth overweight and obesity.
The consumption of sugar sweetened beverages (SSB)8 doubled in the US between 1977 and 2002 (1). Children and adolescents derive 10–15% of their total energy from SSB (2). SSB are not only associated with weight gain but have also been linked to diabetes, dental decay, and displacing healthier options such as milk (3, 4).
Of the low nutrition, energy dense (LNED) foods, SSB have been singled out as a target for policies aimed at reducing youth obesity (5). Limits on their availability have been suggested in schools, where youth are a “captive audience.” In 2006, the American Beverage Association and 3 major beverage firms agreed to limit access to SSB in schools, and many schools have adopted their own policies. However, schools contribute to only a small portion of youth consumption (6) and it is important to curtail availability from other sources, especially in the home environment. If the literature on tobacco is instructive (7), imposing taxes on SSB may be a particularly effective way to reduce youth consumption (8). SSB purchases would not only be discouraged among adolescents and young adults, but also among adults, who serve as role models for youth and purchase most of the SSB consumed by children (2).
Recent reviews (9–11) have considered school nutrition policies, but only James and Kerr (12) focused specifically on school policies directed at SSB consumption. Since their review, many new studies of school policies directed at SSB consumption and pricing have been published. This paper reviews the literature on both these sets of policies.
Although the public health concern is the effect of SSB policies on youth BMI, few studies have examined the effect on BMI and obesity, and those that did often failed to observe significant results. Consequently, we also consider how SSB consumption affects youth BMI. As shown in Figure 1, the effect of SSB policies on BMI involves 3 separate pathways. Reducing energy from SSB may not always translate into reduced total energy intake (TEI): youth may substitute SSB for other foods or beverages that contribute energy. Consequently, we considered studies that examined how changes in SSB consumption translate into changes in TEI and how TEI affects BMI. We attempted to gauge the effect of policies on BMI and highlight areas meriting additional study.
Studies were collected using searches of PubMed, the Social Science Index, and Social Science Research Network by using various combinations of the terms BMI, overweight, obesity, SSB, school, nutrition policies/interventions, and price. In addition, references were identified from pertinent articles, including recent reviews (9–11, 13).
Although some of the literature focused on carbonated beverages (i.e. soda), we considered all SSB beverages, including carbonated beverages, sports and vitamin drinks, and juice drinks. Most of the studies were conducted in the US, but we considered all English language studies from other countries. Because studies examined highly heterogeneous policies, meta-analytic techniques were eschewed. Rather, a comparative approach was employed that focused on the better studies.
Using nationally representative data from the NHANES, Wang et al. (2) found that 79% of U.S. youth ages 2–19 y consumed SSB in 1999–2004, showing little change from 1988–1994. However, among youth who reported SSB consumed on the recalled day, average consumption increased from 252 to 273 kcal/d (1 kcal = 4.184 kJ). Average daily consumption for all youth was 228 kcal (10.7% of average daily intake): 24 kcal (7%) for ages 2–5 y, 184 kcal (9%) for ages 6–11 y, and 301 kcal (13%) for ages 12–19 y. Carbonated drinks contributed 55% and fruit drinks 33% of all SSB energy. On a typical weekday, 55–70% of all SSB energy was consumed at home, whereas 7–15% occurred in school (increasing with age).
Using the 3rd School Nutrition Dietary Assessment Study (2004–5), Briefel et al. (14) found that 68% of school children consumed SSB on a school day. Youth consumed an average of 159 kcal, of which 93 were at home, 36 were at school, and 31 were at other locations. In a separate study, the authors (15) found that SSB were consumed in school by 17% of students in elementary school (ES), 32% in middle school (MS), and 36% in high school (HS), of which only a portion were actually purchased at schools (27% in ES, 67% in MS, and 74% in HS). They (14) found a higher percentage of SSB obtained at school than Wang et al. (2) In addition to differences in the population surveyed, Briefel et al. (14) sampled on school days, whereas Wang et al. (2) sampled on weekdays. Both studies (16) found that most SSB are obtained by youth from home, but both relied on 24-h recall, which is subject to underreporting (17), especially by those who consume the most SSB.
As shown in Table 1, in-school policies to reduce SSB may involve price changes, limits on access, and educational policies. Results of experimental studies are shown in Table 2 and results of population/studies in Table 3. While few of the policies studied were directed solely at SSB, all studies had a component discouraging LNED foods and all reported effects on SSB consumption.
We found no studies that directly examined in-school SSB price policies, but reducing the price of lower fat snacks, fruits, and vegetables in school has resulted in increased sales (18), suggesting that students may be also sensitive to price differentials for SSB.
Using the 2004–2005 School Nutrition Dietary Assessment Study, Briefel et al. (15) found that 34% of students (43% of ES, 35% of MS, and 16% of HS) were in schools that had no “pouring rights” to soda with bottling companies, 78% (94% ES, 84% MS, and 47% HS) had no store or snack bar selling SSB, 15% (24% ES, 6% MS, and 5% HS) had no á la carte food or beverages except skim milk, and 40% (76% ES, 9% MS, and 2% HS) had no vending machines. However, vending and á la carte sales in 15% of MS and 21% of HS were free of LNED foods. Only 25% of schools had a policy that meals average <30% of energy from fats (33% in ES and 15% in MS and HS). The 2006 School Health Policies and Practices Study data (19) also indicates SSB are more accessible in older grades: 33% of ES, 71% of MS, and 89% of HS had either vending machines or a snack bar, and 13% of ES, 29% of MS, and 58% of HS allowed students to buy SSB from a vending machine or in a school snack bar during lunch periods.
For 5th graders, Fernandes (20) found that, of the 40% of children who had access, 26% consumed SSB at schools. Having access in schools increased the odds of consuming any SSB in or out of school in the previous week by 40%. As a result, eliminating access was predicted to reduce the percent who consumed SSB by 4%, with greater reductions among Black non-Hispanics (6%) and girls (5%).
Cullen et al. (21–25) examined the effect of school nutrition policies in a Texas MS with high Hispanic and lower income populations. Cullen and Zakeri (22) found that consumption increased by 60% (from 2.1 to 3.4 oz/d) as children advanced from 5th to 6th grade and SSB became more available, and fell only 10% in the next year. Upon removing LNED from snack bars and in cafeteria vending machines (23), student reported mean SSB school intake declined 35%, but slightly more SSB were obtained from non-cafeteria vending machines and home. However, changes in snack bar SSB sales were not significant, suggesting that results are sensitive to how SSB consumption is measured. In another study (25), a policy limiting portion size (≤12 oz) and vending machine availability was associated with a decline in overall SSB consumption, with little change in home consumption. The absence of compensatory increase in home consumption suggests that school based policy is effective in reducing overall SSB consumption.
Studies of programs in other states have also found that limiting access or serving sizes reduced SSB consumption in MS. In a pilot study conducted in 3 states, Hartstein et al. (24, 26) found that limiting serving size reduced average SSB consumption by almost 50% among students in 2 Texas and 2 California MS but found no change in 2 North Carolina schools. In Washington, Johnson et al. (27) found that SSB policy predicted SSB exposure (measured by vending machine slots and other SSB venues) and that greater exposure predicted higher consumption. Their results imply a 25% reduction in SSB intake between schools with no policy (score = 0) to a strong policy (score = 6). For California, Shi (28) found that adolescents in schools without SSB in vending machines consumed 0.16 fewer servings/d. In Minnesota, Grimm et al. (29) found children 2.4 times more likely to consume SSB 5 times/wk or more if SSB were available in school vending machines. In Massachusetts, Weicha et al. (30) found that SSB consumption increased with vending machines use and fast food restaurant visits.
For HS, Blum et al. (31) found that reduced á la carte and vending machine availability decreased SSB consumption in both intervention and control groups by ~10% after 9 mo. The lack of difference between the 2 groups may have been due to local publicity during the study that influenced both groups. Neumark-Sztainer et al. (32) found that when vending machines were turned off during lunchtime, HS students purchased 25% fewer soft drinks (from 1.9 to 1.4 d/wk). Whereas a study (33) from the Netherlands did not find a significant association between SSB consumption and snack bar access in secondary schools, Vereecken et al. (34) found 40% more daily consumption by those Belgian secondary school students with SSB access in schools but found no difference in primary schools.
In the most comprehensive study of school access policies to date, Briefel et al. (15) found that SSB consumption was reduced by 22 kcal/school day (P < 0.01) in MS and by 28 kcal in HS (P < 0.01) without stores or snack bars, by 16 kcal (P < 0.05) in MS without a pouring rights contract, by 52 kcal (P < 0.01) in MS with no á la carte offerings, and by 40 kcal (P = 0.07) in HS with stricter rules against vending machines. Whereas their results indicate that some policies lead to large reductions in average SSB consumption, many were found to have no effect due to the difficulty in distinguishing their effects. Using an overall index of policies, their results indicated that daily SSB consumption was reduced by 48 kcal in MS and 56 kcal in HS with the strictest access policies compared to schools with no access restrictions and was 77 kcal lower in HS with the strictest meal practices. Relative to average consumption in schools with strict minimal policies, these reductions imply a 30% decrease in both MS and HS by the 21 and 27% of students, respectively, buying SSB in MS and HS, and by 40% from improved meal practice of the 27% purchasing SSB in HS. No effects were found in ES.
Woodward Lopez et al. (35) examined how the California nutrition standards bill affected SSB availability and consumption in and out of schools. They found substantial reductions in the availability of soda and other sweetened beverages but an increase in sport drinks. They found that soda consumption at school fell by 8%, with minimal and nonsignificant increases at home. Water consumption increased at school and home.
The National School Lunch Program (NSLP) provides limited SSB. Briefel et al. (14) found that students in the NSLP consumed 28 kcal less SSB energy in ES and 16 kcal in secondary schools than nonparticipants. Condon et al. (36) found that NSLP participants consumed less energy from sodas (3% in NSLP vs. 16% in non-NSLP, but 8 vs. 25% in HS) and sugar-sweetened juices (9% in NSLP vs. 27% in non-NSLP, but 4 vs. 31% in ES).
Forshee et al. (37) considered in-school SSB consumption and BMI but found no effect on BMI among those aged 13–18 y after removing SSB from school vending machines. Fletcher et al. (38) also found little effect on weight of SSB availability in vending machines. Although not explicitly distinguishing the effect on SSB consumption (and not reported in Table 3), 3 studies found varying effects of school access to LNED foods on BMI (39–41).
In 2006, 70% of states required nutrition and dietary behavior to be taught at the ES, MS, and HS levels as part of the health education curriculum (42). Briefel et al. (15) found no relationship to SSB consumption for nutrition education programs. Vereecken et al. (34) found that having a school policy against SSB access was associated with 18% less SSB consumption but found no relationship with education programs in either primary or secondary schools.
Three randomized control trials examined the effects of school education programs targeted at SSB consumption. James and Kerr (43) reported that SSB consumption over 3 d decreased by 0.6 servings (0.8 oz. or 236 mL) in the intervention group receiving an ES curriculum while increasing by 0.2 servings in the control group. At 12 mo, the percentage of overweight youth decreased 0.2% in the intervention group while increasing 7.5% in the control group, but the difference had disappeared within 2 y after the program ended (44). For an education program aimed at discouraging SSB among Brazilian students aged 9–12 y, Sichieri et al. (45) found that daily consumption of carbonated SSB decreased in the intervention group by ~20%, with almost no change in the control group. The participants who were overweight at the beginning of the trial had a greater reduction in BMI, but the reduction was only significant for girls. In a 6-wk school nutrition education program directed at Canadian 9th graders, Lo et al. (46) found that peer educator classes (intervention) significantly reduced SSB intake at 3 mo compared with the self-taught classes (control). However, the effect disappeared after 1 y, possibly due to the lack of refresher courses.
Policies that limit SSB availability and improve food offerings in school lunches have generally been associated with reduced SSB consumption. Policies restricting access in MS can reduce the percent of students consuming SSB by 25% (27) and the energy consumed by those students by 30% (15). Some studies indicate less effect, while studies by Cullen et al. (21–25) generally obtain larger effects. Fewer studies have been conducted for HS, but reductions of energy intake on the order of 30% (15) from access policies and 40% from improved meal practices were observed for the 27% of students buying SSB. Restricting SSB availability in vending machines and snack bars appears particularly effective. Whereas an experimental study found more prominent effects on those at higher BMI, such differences were not reported for cross-sectional studies (14). The role of initial weight, race/ethnicity, and socioeconomic status (SES) merit further attention.
Cross-sectional studies generally have not found that nutrition education programs reduce SSB consumption, although none of these programs targeted only SSB. Experimental education programs targeting SSB showed effects on students with higher initial BMI, but the effects faded after the programs stopped.
The effects of nutrition policies on BMI are less conclusive. Most of the studies considered a limited set of policies and have not examined the effect of school access policies over a period of longer than 2 y. The lack of evident impact of SSB policies on BMI may be due to the lack of an adequate follow-up period or may indicate that reduced SSB consumption in school is compensated by increased SSB consumption outside of schools or by increased intake of other LNED foods. However, studies (14, 20, 35, 47) have not found increased SSB consumption at home in response to reduced consumption in schools. In addition, lunch policies discouraging LNED consumption (e.g. French fries) were associated with reduced SSB consumption (15).
Unlike school nutrition policy, tax policies apply to all purchasers, not just those in school. Price may be increased through a direct tax on SSB or through disfavoring SSB from sales tax exclusion. Taxes have been imposed mostly on sodas. In 2007, 34 U.S. states taxed soda sold in grocery stores and 39 states taxed soda sold through vending machines at mean rates of 3.4 and 4.0%, respectively (48). The tax was never >10% of the price.
Table 4 summarizes studies on the effect of soda taxes on youth. Using a large, nationally representative survey, Powell et al. (49) found no effect of state level soda taxes on adolescent BMI, but found a weak effect of vending machine soda tax rates on BMI among teens at risk for overweight. A 1 percentage point increase in the vending machine tax rate was associated with a 0.006-kg/m2 reduction in BMI among adolescents at risk of being overweight (P = 0.09). Sturm et al. (50) examined the effect of taxes on young school children and found limited effects on soda consumption or BMI, although stronger effects were observed for those with high income and those with high BMI. Using regression analysis, Fletcher et al. (51) found no effect of soda taxes on BMI or the probability that a youth consumes soda, but a 1% increase in the tax rate was associated with nearly 8 fewer kcal from soda consumed (P < 0.05), an approximate 6% reduction. Using the same dataset to examine mean BMI and soda consumption, Fletcher et al. (38) found no significant differences associated with differences in state taxes.
For adults, Kim and Kawachi (52) found no difference in obesity rates between states with and states without a ≥5% tax, but states repealing a soft-drink or snack food tax had an increase in obesity. Fletcher et al. (53) found that a 1% increase in the soda tax rate decreased BMI by 0.003 points and had a greater effect on low income and Hispanic adults. Although they did not distinguish beverages, Miljkovic et al. (54) found that a 10% increase in the price of sugar products was associated with a decrease in the prevalence of overweight by 2% and of obesity by 8%.
Although no study found a substantial effect of soda prices on BMI, demand studies generally found that price affects soda consumption. A recent review (55) concluded that the price elasticity for soft drinks is in the range of −0.8 to −1.0. For low-income consumers, Yen et al. (56) found that a 10% price increase was associated with an 8% reduction in soda consumption, with little effect of soda prices on the consumption of other beverages. Smith et al. (57) obtained SSB own price elasticities of −1.3, but found some evidence of cross-price elasticities with other beverages, indicating some offsetting effect. A 20% SSB price increase was found to reduce SSB energy intake by 38.8% for adults and 48.8% for youth, with an offset of 1.9% for adults and 6.1% for youth.
In sum, past studies have considered relatively small variations in soda tax rates that were generally applied to a limited set of SSB, thus providing weak evidence on their relationship to weight. Powell and Chaloupka (13) concluded that substantial tax increases will be necessary to have potent effects. Estimates from Andreyev et al. (55) imply that a tax increase at 20% of current prices would reduce consumption by between 16 and 20%. A 16–20% reduction in youth SSB consumption would translate into a reduction of 36–45 kcal, assuming average intake of 225 kcal (2). Although the studies do not distinguish youth, Epstein et al. (58) found that youth food consumption was closely related to purchases by their parents. Furthermore, studies have found that youth at risk for overweight and from low-SES families are particularly sensitive to fruit and vegetable prices (59, 60) and that high-BMI youth (61, 62) are more sensitive to food prices than low-BMI youth, suggesting that higher SSB taxes may have a greater impact on youth than on adults and on those at a high BMI or from low-SES families. However, if a tax is applied only to sodas, youth may substitute with nontaxed SSB and/or other LNED foods.
Reviews by Malik et al. (3) and Vartanian et al. (4) support a strong relationship of SSB consumption to BMI for adults and youth. A meta-analysis funded by the American Beverage Association (63) found almost no relationship of SSB to BMI, but that study was found (64) to be subject to scaling errors and failing to allow for the full impact on BMI (because TEI was held constant).
Three longitudinal studies found youth SSB consumption related to weight. For 11,654 youth ages 9–14 y followed for 3 y (65), BMI increased by 0.04 kg/m2 (P < 0.01) for boys who increased soda consumption by 1 serving/d in the previous year. An increase of >2 servings/d was associated with a 0.14-kg/m2 increase in boys (P < 0.01) and a 0.10-kg/m2 increase in girls (P = 0.05). For 548 youth aged 11–12 y followed for 19 mo, Ludwig et al. (66) found a 0.24-kg/m2 (P < 0.03) increase for each 8 oz. of SSB/d, and the odds of obesity increased 60% for each additional serving. For 10,904 low-income children ages 2–3 y followed for 1 y, Welsh et al. (67) found that SSB consumption was related to normal weight children becoming overweight (OR ≈ 1.5) and to overweight children remaining overweight (OR ≈ 2). Two recent studies (68, 69) also found SSB consumption related to the BMI of low-income, young children.
During a 25-wk experimental program delivering noncaloric beverages to adolescents’ homes, Ebbeling et al. (70) found that the intervention group’s consumption of SSB decreased by 82% and BMI was reduced by 0.75 kg/m2 for the heaviest 3rd of the group, with no change in the control group. The experimental study by James and Kerr (43) obtained similarly large effects. Cross-sectional studies (3, 63, 64) obtain mixed results, but may be subject to bias if those at a high BMI abstain from consuming soda or switch to diet soda as part of a weight-loss strategy.
Studies of the effect of SSB consumption on BMI are often underpowered, have a short follow-up, or use weak assessment methods, e.g. a single 24-h recall (3). However, Ludwig et al. (66) found that, by replacing SSB, the BMI of those aged 8–12 y could be reduced by between 0.1 and 0.24 kg/m2 over 19 mo, which translates to between 0.035 and 0.08 kg/y, a substantial portion of the 0.25-kg reduction needed to maintain appropriate weight (71). They also found that BMI depends on initial SSB consumption as well as changes in consumption, suggesting that diet history is important. Results from Ebbeling et al. (70) imply that BMI is reduced by 0.26 kg/m2 for every serving per day of SSB displaced, comparable to the increase obtained by Ludwig et al. (66) Chen et al. (72) found that a reduction in SSB intake of 1 serving (12 oz.)/d was associated with a weight loss of 0.5 kg at 6 mo and 0.65 at 18 mo.
Wang et al. (73) compared 2 nonconsecutive 24-h dietary recalls of beverage consumption from the 2003–2004 NHANES to determine how intra-individual SSB consumption affects TEI. Each additional 8-oz. serving of SSB was associated with a net increase in intake of 106 kcal on that day (P < 0.001). This is similar to the 100 kcal found in an 8-oz serving of colas and lemon-lime sodas, suggesting no compensation. Each 1% of SSB beverage replacement with water was associated with 6.6 kcal lower TEI, which would result in an average reduction of 235 kcal among U.S. youths. Although the extent of compensation did not differ by age, they found a reduction of 172 kcal for ages 2–5 y, 183 kcal for ages 6–11 y, and 302 kcal for ages 12–19 y, all due to differences in average consumption. Although energy intake was 80–90 kcal higher in those with a BMI ≥ 85th percentile than those with a BMI < 85th percentile, the difference was not significant.
Lack of compensation is also supported by several other studies, as demonstrated in a recent meta-analysis by Vartanian et al. (4) In general, compensation appears to be no more than 50% and some studies find that SSB may lead to increased energy consumed from other foods.
Inferred from observed population weight changes, Hill et al. (74) found that reducing energy balance by 100 kcal “could prevent weight gain in the majority of the population.” However, Butte and Ellis (75) argued that the energy gap was higher for children, especially those overweight, due to greater energy expenditures. Studies indicate that the required energy reductions to prevent weight gain vary by age, initial weight, and physical activity levels; lower estimates of 100–140 kcal were indicated at younger ages by Plachta-Danielzik et al. (76) and Wang et al. (71), mid-range estimates of 300–500 kcal at slightly higher ages were obtained by Swinburn et al. (77) and Butte et al. (75, 78), and upper estimates of 600–1100 kcal were obtained by Wang et al. (71) for those who became overweight adolescents over 10 y. The results indicate that relatively modest behavioral modifications are required to prevent weight gain at younger ages, but larger reductions are required at higher weights and higher ages.
The research to date provides promising results indicating that, like the effects of policies on other public health problems such as tobacco use, policies can play an important role in decreasing SSB consumption and obesity rates among youth. In MS, studies have found lower youth SSB intake in school with policies directed at reduced access to vending machines, snack bars, and á la carte. Although there is less evidence for HS, access policies and improved meal practices still hold potential to significantly reduce the amount of SSB consumed. One critical insight from several studies is that reduced SSB consumption in schools is unlikely to be offset by increased SSB consumption outside of schools.
Studies also find that higher prices reduce overall SSB consumption. Although the effect of price on youth merits further study, research indicates that price increases will influence adult as well as youth purchases and will affect purchases inside and outside of school. They may have the greatest impact on youth who are overweight or from low-income families, but additional study is warranted.
Although several long term longitudinal studies have established the role of SSB and increased BMI, and school access, nutrition, and price policies have been shown to reduce SSB consumption, the direct estimate of these policies’ effects on BMI is less conclusive. Another line of research has found that, due to the lack of offset from consuming other foods or beverages, overall energy intake appears to decline by as much as and perhaps more than the decline in energy from SSB. The reduction in energy intake from even just one 8-oz. serving of SSB appears enough to have important effects on the prevalence of overweight and obese youth if policies are started at early ages and maintained.
The policy studies reviewed involve data collected before recent U.S. policies to reduce SSB consumption in schools. With access to LNED foods reduced since 2005 (40), new studies will need to track SSB consumption inside and outside of schools and examine their effects.
While some studies consider more than one policy, they often do not explicitly consider how the effects of a policy may depend on the other policies in effect or how the effects vary by initial BMI, racial/ethnic group, and SES. Furthermore, the effects of policies may depend on exposure to past policies. For example, the effects of a MS program may depend on whether the child has been exposed to similar programs in ES, because those programs may have already affected their consumption habits and knowledge about nutrition. The effects of a specific policy may also vary over time. Research (79) indicates that the likelihood of being overweight depends not only on parents, but also peers, suggesting that the effects of a policy may be amplified as its effects spread through social networks. On the other hand, the effects of a policy could diminish over time if food manufacturers adapt their marketing practices to maintain sales of SSB or if individuals adapt by consuming other LNED foods.
Other policies besides those considered above, such as limits on advertising, parent-student educational polices, or nonschool mass media policies, may also be used to reduce SSB intake. Although studies indicate that advertising affects LNED consumption (80), research is needed on the population effect of advertising restrictions and public media campaigns on SSB consumption. In addition, further study is needed on how the effects of nutrition policies may be enhanced by physical activity policies.
Obesity is a complex problem, and solutions appropriate for complex problems are required. Better information is needed on how the effects of policies unfold over time as an individual ages and how changes in consumption patterns affect future dietary preferences and BMI trajectories. Empirical studies will need to use longitudinal data to consider these interrelationships over time. Alternatively, information from different studies may be combined in a modeling framework that explicitly considers the links from a policy change to reduced SSB consumption to lower BMI, as well as how policy effects may maintain or taper with age.
Because the effect of SSB has probably been studied more than other types of food and the links to BMI are relatively well understood, longitudinal studies and simulation models of the effects of SSB policies can also provide guidance to help better understand the effects of policies directed at other food types.
D.L. and K.F. analyzed data; D.L. wrote the first draft, and K.F. and C.W. revised the draft and provided extensive comments; D.L. had primary responsibility for final content. All authors read and approved the final manuscript.
1Published in a supplement to Advances in Nutrition. Presented at the conference “Forum on Child Obesity Interventions” held in Mexico City, Mexico, November 17–19, 2009. The conference was organized and cosponsored by Fundaciόn Mexicana para la Salud A.C. (FUNSALUD). Its contents are solely the responsibility of the authors and do not necessarily represent the official views of FUNSALUD. The supplement coordinator for this supplement was Guillermo Melendez, FUNSALUD. Supplement Coordinator disclosures: Guillermo Melendez is employed by FUNSALUD, which received a research donation from Coca Cola, PEPSICO, and Peña Fiel, three major beverage companies in Mexico, to support the program of childhood obesity research and communication. The supplement is the responsibility of the Guest Editor to whom the Editor of Advances in Nutrition has delegated supervision of both technical conformity to the published regulations of Advances in Nutrition and general oversight of the scientific merit of each article. The Guest Editor for this supplement was Nanette Stroebele, University of Colorado, Denver. Guest Editor disclosure: Nanette Stroebele declares no conflict of interest. Publication costs for this supplement were defrayed in part by the payment of page charges. This publication must therefore be hereby marked "advertisement" in accordance with 18 USC section 1734 solely to indicate this fact. The opinions expressed in this publication are those of the authors and are not attributable to the sponsors or the publisher, Editor, or Editorial Board of Advances in Nutrition.
2Supported by the Robert Wood Johnson Foundation under grant no. 63048; honoraria provided to D. Levy and K. Friend by Fundación Mexicana para la Salud.
3 Author disclosures: D. T. Levy, K. B. Friend, and Y. C. Wang, no conflicts of interest. An earlier version of this paper was presented at the Forum on Child Obesity Interventions of FUNSALUD.
8Abbreviations used: ES, elementary school; HS, high school; LNED, low nutrition, energy dense; MS, middle school; NSLP, National School Lunch Program; SES, socioeconomic status; SSB, sugar sweetened beverage; TEI, total energy intake.