Making Progress on Added Sugar: Nutrition Policy After The Pandemic

by Leah Butz

“I think that reducing sugar is a critically important public health issue. Sugars have no nutrients but calories; they’re empty calories. There’s an enormous amount of evidence that people who eat a lot of sugar are at higher risk for weight gain, chronic disease, and, therefore, poor outcome from COVID-19.” That was Dr. Marion Nestle, Paulette Goddard Professor of Nutrition, Food Studies, and Public Health at New York University. Nestle moderated a series of three panels about added sugar policy co-hosted by the Hunter College NYC Food Policy Center and the Center for Science in the Public Interest. 

Panelists came from all over the country and helped the audience better understand policies related to added sugar. As the COVID-19 pandemic comes to an end, new, healthier and more equitable food environments need to be created. How can policy address public health and food justice when it comes to added sugar?

Panel 1: Sugar and Institutions: What’s Been Done, and What Needs to Be Done

Panelists:

  • Nichola Davis, MD, MS, Vice President, Chief Population Health Officer at NYC Health + Hospitals 
  • Elizabeth (Liz) Solomon, MS, RD, Director, Nutrition Policy & Programs, NYC DOHMH
  • Pam Koch, EdD, RD, Executive Director, Laurie M. Tisch Center for Food, Education & Policy, Program in Nutrition
What has been done already?

Nestle kicked off this discussion with a deep-dive into the current status of sugary food and drink in NYC institutions, paying particular attention to NYC Health + Hospitals and the NYC Department of Education. 

Nestle asked Dr. Nichola Davis, the Chief Population Officer at NYC Health + Hospitals, about the agency’s move to eliminate sugary drinks from all locations. How did NYC Health + Hospitals manage to pull it off? Was there any pushback, and, if so, how was it dealt with? Davis is an internist by training and an obesity specialist, so the issue of healthier hospital food is one that she is particularly interested in, and she was part of a workgroup of professionals who are passionate about obesity that was formed a few years ago. One strategy the group came up with was to begin to tackle the issue of sugar. “Everyone, in theory, agreed that hospitals shouldn’t sell sugary beverages,” Davis said, adding, “We can’t talk to patients upstairs about not drinking soda and then let them go downstairs and buy sugary soda.”

She noted that NYC Health + Hospitals had already demonstrated interest in changing the food served at their institutions, including a move toward plant-based meals as the default for patients. And, luckily they were already in the midst of renegotiating their food and drink contracts with their vendors. Many different members of the obesity workgroup had to approach the hospital administration from various angles, because there was plenty of skepticism about how effective a sugary-drink-ban would be. The conversations and efforts lasted for two years. Eventually the workgroup’s efforts reached the CEO of NYC Health + Hospitals who greenlit the removal of sugary drinks, something that Nestle described as “miraculous.” 

The next panelist was Elizabeth Solomon, the Director of Nutrition Policy & Programs at the NYC Department of Health and Mental Hygiene (DOHMH). Nestle asked her, “How does the DOHMH work to reduce sugar? Can you give us some idea of the scope of what you’re doing and whether it’s working or not? What are you up against?” “Healthy eating is very challenging for New Yorkers,” Solomon said. Unhealthy food is ubiquitous, and marketing for unhealthy food is especially pervasive throughout New York City. The DOHMH’s goal is to make it easier for New Yorkers to make healthy choices. This is a huge task, because, as Solomon said, “We’re up against big powerful systems” in the food industry that have a lot of money to spend on marketing and advertising. 

The DOHMH acts as a technical advisor on food standards for all meals served by city institutions (230 million meals per year), and these standards are updated every three years. The current standards limit sugary drinks and snacks and encourage whole food consumption. Furthermore, the DOHMH acts as a leader of the National Salt and Sugar Reduction Initiative, which calls on the food industry to reduce salt and sugar in packaged foods and works to support community organizations who promote healthy beverage consumption and awareness campaigns.

Solomon acknowledged the disparities among communities with relation to public health, saying, “The root causes of health inequities involve systems of oppression, including racism and power imbalances.” There is currently an inequitable distribution of resources for health and access to healthy foods, with marginalized and underserved communities receiving far fewer healthy resources than affluent communities. These underserved communities (especially Black and Latinx communities) receive far more advertising for unhealthy foods than for healthy foods. 

The final member of this first panel was Dr. Pam Koch, the Executive Director of the Laurie M. Tisch Center for Food, Education & Policy. Koch has a background in education, so Nestle went straight to the point: Why is it so difficult to get sugar out of schools? Koch said that much of the issue has to do with norms: right now, the norm for many students is to grab a sugar-sweetened beverage and a sugary snack before school, usually because those types of foods are their only options. Students have indicated that they want to make healthy choices, but their families and communities do not have enough resources from which to access healthy food. “They’re making food choices in an environment that is making it hard for them to be their best selves,” she said. The school system has made efforts to teach students about nutrition; however, Koch said, “Nutrition education can’t work if the environment is so incredibly toxic.”

The attitudes of teachers, school staff, and other adults also greatly affect how students feel about healthy eating. If the adults care about what kids eat, then kids are more likely to take the healthy meals offered by the school. Unfortunately, the attitudes of these adults vary tremendously from school to school. When kids come back to school full time in the post-COVID world, Koch notes, there will be a huge opportunity to remake the school lunch system into one that is supportive of healthy eating through cafeteria design, scratch cooking, and consistently supportive attitudes from adults. 

Nutrition standards: yea or nay?

Nestle expressed her concern about nutrition standards, saying, “They seem so gameable.” She asked the entire panel if they thought it possible to move to nutrition standards that completely eliminate processed foods. 

“Get back to the basics,” Davis said. People will always try to work around the standards, and largely are able to because of how complicated nutrient-based standards are. Koch agreed, saying, “If you have nutrient-based standards, basically you can have ‘formulated foods’ that are meeting those nutrient standards without actually being healthy foods.” It then becomes much more difficult for people to know what exactly is healthy and what is not. If the standards get back to the basics, such as fruits and vegetables, it will be more difficult for institutions to work around those standards with ultra-processed foods. 

Fortunately, Solomon said, the city is in the middle of updating its food standards. They look at current nutrition research, federal recommendations and general feasibility when writing the food standards. The current food standards also do encourage whole foods and recommend the phasing out of processed meats. 

What do we do about food marketing?

Nestle’s final question to the panel was about food marketing, and all the panelists agreed that the marketing of unhealthy, high-sugar foods needs to be reduced. The city should look at its own policies to find opportunities to reduce advertising and put public health campaigning first. Koch summed it up well: “Marketing works, which is why they do it. So it needs to be reduced.”

Panel 2: Pouring Rights Contracts at Public Universities

Panelists:

  • Jen Falbe, PhD, Assistant Professor of Nutrition and Human Development, University of California, Davis
  • Richard Black, PhD, Principal, Quadrant D and former Vice President of Global Nutrition Sciences, PepsiCo
  • Kelly Garvey, Research Assistant, University of California, Santa Barbara 
What are pouring rights contracts, and why do they matter?

The second panel began with a brief definition from Nestle of “pouring rights.” A pouring rights contract is one between an institution, such as a sports arena, an event venue, or a university, and a beverage company, which gives the beverage company exclusive rights to sell their drinks in that venue. For example, Nestle said, New York University is a Coca-Cola campus, meaning all beverages sold on the campus are produced by the Coca-Cola Company. For the purposes of this panel, the conversation focused specifically on pouring rights contracts at public universities.

The first panelist was Dr. Jen Falbe, an Assistant Professor of Nutrition and Human Development at the University of California, Davis. Her work looks at policies that reduce sugary drink consumption, including taxation and the addition of warning labels. She is also the faculty lead for the University of California-wide Healthy Beverage Initiative, whose major goal is to install water stations around campus and create environments that do not put sugary drinks front and center. Falbe argues that pouring rights contracts interfere with healthy beverage initiatives, because some contracts even require that sodas must be sold wherever other beverages are available. 

Nestle asked Falbe where issues of food justice and equity fit into the discussion of pouring rights contracts. Students at the University of California have expressed a desire to purchase beverages from local businesses, particularly those that are woman- and minority-owned. Pouring rights contracts make doing so much more difficult, as they cannot find any such products on campus. and often the drinks available on campus are sold at a price higher than the usual retail cost. Students are taken advantage of because they have no other options for what to drink on campus. 

The second panelist was Dr. Richard Black, a Principal at Quadrant D Consulting and former Vice President of Global Nutrition Sciences at PepsiCo. Given his background in the beverage industry, Nestle asked him if soft drink companies can become part of the solution to promote healthier beverage environments on college campuses. It’s possible, he said, but first, “you have to understand the incentives that the purchasing people within the university are working with.” Soft drink companies provide financial incentives (similar to “bonuses”) to universities for selling more and more of the product. “The company isn’t interested in selling sugar. The company is interested in selling beverages,” he added. Universities have the opportunity to write up contracts that promote less sugary options, and companies can provide better “bonuses” to campuses that sell the healthier options. 

Kelly Garvey, the third panelist, is a Research Assistant with the Healthy Beverage Initiative at the University of California, Santa Barbara. She graduated from the university in June of 2020, having majored in anthropology and environmental studies, and her research work focuses on reducing sugary drink consumption and increasing tap water consumption on the university’s campus. The research she does for the Healthy Beverage Initiative is about more than just the adverse health effects of sugar-sweetened beverages (SSBs). It also looks into the environmental impact of all bottled beverages. The Initiative wants to see how universities can reduce their environmental impact by eliminating pouring rights contracts. 

Garvey was asked about student activity surrounding pouring rights contracts. What are student opinions on the current contracts? Garvey said that the current beverage environment, which was created in 2014 and without consulting students, is not what current students want. “Students are the backbone of universities and are left in the dark about these business decisions,” she said, noting that many students (especially those in the Environmental Studies program) are very conscientious about reducing their environmental impact and want places to refill their water bottles rather than purchase bottled drinks. She also brought up the ethical issues of what’s included in pouring rights contracts, many of which include plastering the drink company’s logo on sports jerseys and university swag. “What company wouldn’t want their name one the backs of these all-star players getting drafted to the NFL?” she asked.

What should be done with the revenue from pouring rights contracts?

Nestle posed a question to the entire panel: Is there some way to make the revenues from pouring rights contracts useful? She wrote about the contracts more than 20 years ago, when most of the money went to sports equipment. Is that still the case?

“Yes, athletics is still a large recipient,” said Falbe. Some money might also go to dining services, or to student groups. At many schools, however, the money from these contracts “is a fraction of a fraction of a percent of the operating budget,” and the revenue from these contracts is less than the public often perceives. The cost of treatment for diet-related disease caused by sugary beverages, however, is getting higher and higher. 

Black added that different university departments see the loss of pouring rights money differently. Dining services will be hurt financially by a reduced income without a pouring rights contract, but they are not aware of the university-wide financial benefit of reduced healthcare costs. There’s a false sense that pouring rights money is critical, but it’s not. “It’s the way the university budget, as a whole, is structured,” he said. Garvey agreed, saying, “It really only is an issue of moving money around.”

What are the next steps?

Nestle ended the discussion with a question about what activists and advocates should do next with reference to pouring rights contracts. Black was first to respond, saying that people should try to understand the incentives driving the choice to sign a contract. Short-term promises of money are a significant driver for companies to engage in these contracts. 

Falbe added that activists should familiarize themselves with what exactly is in the contract. Some contracts stipulate that there must be a minimum number of vending machines on campus, or that beverages for sale have to be displayed at eye level. She recommended MuckRock’s database of pouring rights contracts and reminded people that within state law, any contract of  this kind can be requested by the public.

Garvey’s final piece of advice was to ensure that the topic is brought up “often, consistently, and in a lot of contexts.” The issue of pouring rights is about more than just public health; it also  affects ethics and the environment . 

Panel 3: (Added) Sugar Warnings at Restaurants

Panelists:

  • Julio Salcedo, Teens for Food Justice intern and Lehman College Nutrition student
  • Aviva Musicus, ScD, Postdoctoral Research Fellow, Harvard T.H. Chan School of Public Health
  • Sarah Sorscher, JD, MPH, Deputy Director of Regulatory Affairs at the Center for Science in the Public Interest
Should we implement added sugar warning labels?

New York City has passed a law requiring sodium warnings on chain restaurant menus, and many Latin American countries have been requiring graphic warning labels on packaged foods high in added sugar, salt, or certain types of fat. Nestle began the final panel with a simple question: Should we implement added sugar warning labels on restaurant menus as well?

The first panelist to speak, Julio Salcedo, is an intern with Teens for Food Justice and a student of Nutrition at Lehman College. He is an immigrant from the Dominican Republic and a first-generation college student. He feels especially passionate about improving the nutrition literacy among the general public, so that everyone can make healthy choices. “There’s another pandemic, and it’s not COVID-19; it’s obesity, it’s chronic diseases,” he said. Warning labels are a start, because they spread awareness. He added that the public needs to know more than just that a certain item is unhealthy—they need to know that unhealthy options have negative health consequences. “We are not putting enough effort into educating people,” because many marginalized and underserved communities are not receiving the resources they need to learn how to make healthy choices. 

The next panelist was Dr. Aviva Musicus, a Postdoctoral Research Fellow at Harvard T.H. Chan School of Public Health. Much of her research focuses on how we can use labeling to avoid diet-related disease. She is currently working with Dr. Jen Falbe to explore the effect of added sugar warnings on restaurant menus. Previously, she published  a study showing that added-sodium warning labels on restaurant menus do affect the choices consumers make. “Americans generally are unaware of how much added sugar is in restaurant foods and beverages, and I think they would be very surprised how high in sugar a lot of these foods that they’re ordering are,” she said regarding the potential for added sugar warning labels.

Musicus expects two outcomes from added sugar warning labels: 1. People will be able to make healthier choices at restaurants, and 2. Restaurants will be nudged to reformulate their recipes to contain less added sugar. Nestle asked about “hidden” sources of added sugar in restaurant food, and Musicus said the most surprising is salads. People often choose a salad thinking it is the healthy option, but they do not realize that they often come with a large amount of dressing that is high in sugar. 

The final panelist was Sarah Sorscher, the Deputy Director of Regulatory Affairs at the Center for Science in the Public Interest (CSPI). CSPA has been doing plenty of work to promote sugar label warnings as part of their larger goal, which is to improve the quality of information consumers receive about food. The organization tries to stop misleading marketing and promote basic transparency measures such as calorie counts and nutrition facts. “It’s really a losing game, going after misleading marketing claim-by-claim. The food industry is always one step ahead,” Sorscher said. Warning icons on chain restaurant menus, however, could help legislators get ahead of the food industry by forcing them to speak truth about their products from the start. She also agreed with Salcedo that nutrition information on its own is not enough, because it requires that consumers have some nutrition literacy and motivation to eat healthier. 

When asked by Nestle about the legal challenges that warning labels face, Sorscher noted that the soda industry is “very litigious.” NYC was sued for the sodium labels, but the case was ultimately dropped, likely because of how uncontroversial the law requiring the sodium icon actually is. In order for an icon to be required, a dish must have more than a recommended day’s worth of sodium. Many opponents to warning labels weaponize the first amendment, arguing that warnings restrict the companies’ ability to communicate information about their products. She ended on a piece of advice to legislators and activists: “Always talk to your lawyer when thinking about policy design.”

Do people even use warning labels?

Nestle  asked the panel if warning labels are actually used by consumers, and, if not, what can we do to make sure they are? 

Salcedo emphasized that people need to be taught what added sugar and unhealthy foods will do to a person’s body. Musicus agreed that education efforts should be funded to improve consumers’ knowledge of nutrition, especially in underserved communities where calories and healthiness are not the first thing families look at when making their purchasing decisions. Salcedo brought up public advertising, similar to the campaigns to wear masks in public during the COVID-19 pandemic, as a potential tool the city could use to promote nutrition literacy. 

Musicus and Sorscher also talked about the fact that restaurants will be forced to rethink the foods they are offering, and potentially reformulate recipes to avoid having to print the warning labels. If recipes are reformulated, consumers will not have to change their own behaviors. 

Is now the right time to be having this conversation?

The panel ended with one final question from Nestle: “Restaurants have been hit especially hard by the pandemic. Is this the right time to be thinking about this?” 

“Yes, this has been a tough time for restaurants, but it has also been a tough time for humans,” said Musicus. Now is a great time to help consumers understand what they’re eating, especially as people begin going back to restaurants. “People are buying takeout and delivery more than ever,” said Salcedo, and should receive more information about what they’re buying. 

Sorscher explained that the pandemic has created a “profound moment,” and many people are rethinking how they live their lives. Now is the time to look at how we can recreate food environments to ensure that communities come back stronger than ever and more prepared for the next pandemic. 


Watch the full webinar here, and access a list of resources about added sugar policy here.

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