Testimony and Statement of Charles Platkin, Ph.D., J.D., M.P.H., Distinguished Lecturer, Hunter College, CUNY; Executive Director, Hunter College New York City Food Policy Center and Annette Nielsen, MA, Acting Executive Director, Hunter College New York City Food Policy Center
Title of Hearing: NYC’s Efforts to Address the Growing Diabetes Epidemic, Introduction of Legislation Int. 687 and Int. 675
February 1, 2023
Thank you to Chairperson Schulman and the members of the Committee on Health for the opportunity to submit written testimony regarding NYC’s efforts to address the growing diabetes epidemic and two pieces of legislation, Int. 687 – a local law in relation to requiring added sugar notifications for menu items in chain restaurants, and Int. 675 – a local law in relation to requiring the Department of Health and Mental Hygiene to create a telemedicine accessibility plan.
We are providing this testimony on behalf of the Hunter College New York City Food Policy Center, of which we serve as executive director and acting executive director. The Center was created in 2012 to develop collaborative, innovative and evidence-based solutions to prevent diet-related diseases, promote healthy eating and reduce food insecurity in New York City and other urban centers. We work with policy makers, community organizations, advocates and the public to create healthier, more sustainable food environments.
Diabetes Facts and Data
Diabetes, a chronic disease marked by heightened blood glucose levels, affects more than 37 million Americans — more than ten percent of the United States population.1 In New York City, nearly one million residents have diabetes.2,3
Diabetes disproportionately affects New York City’s communities of color.4,5,6,7,8 The Bronx has the highest rate of diabetes among adults of the five boroughs, with 12 percent of adults having diagnosed diabetes.9 This includes majority Black and brown communities such as Belmont, East Tremont, Hunts Point, and Melrose, all of which have more than 20 percent of residents with diagnosed diabetes.10 These communities are also disproportionately represented in the number of avoidable diabetes-related hospitalizations.11 Furthermore, many of these marginalized communities are not receiving the educational resources they need for residents to understand the impact of their dietary choices on the development and outcomes of these diseases.12
This epidemic results in high costs, both in money and in lives. Diabetes is the sixth leading cause of death for adults in New York City.13 Furthermore, it is often comorbid with other chronic and life-threatening conditions, such as hypertension and heart disease.14 Individuals with diabetes are also at greater risk of poor outcome from COVID-19.15 Financially, the cost of diabetes is enormous — according to the American Diabetes Association, “Diagnosed diabetes costs an estimated $21 billion in New York [State] each year,”16 which includes both direct medical expenses and indirect loss of productivity costs.
The Health Impact of Added Sugars
The American Heart Association defines added sugars as “sugars and syrups put in foods during preparation or processing, or added at the table.”17 The top sources of added sugar in the American diet come from soft drinks, fruit drinks, flavored yogurts, cereals, cookies, cakes, candy and most processed foods.18 Added sugars contribute calories but no essential nutrients to one’s diet.19 The 2020-2025 Dietary Guidelines for Americans, released by the US Department of Agriculture and the US Department of Health and Human Services, recommend eating no more than 50 grams (12 teaspoons) of added sugar per day for a 2,000 calorie diet20 and the American Heart Association recommends no more than six percent of calories come from added sugar each day, which amounts to 30 grams (~7 teaspoons) of sugar for a 2,000 calorie diet.21 Yet American consumption of added sugar far exceeds these recommendations with adults consuming an average of 77 grams (17 teaspoons) of added sugars per day and children consuming 81 grams (19.5 teaspoons) of added sugars per day.22
The deleterious effects of excess sugar on health is clear and well documented.23,24,25,26,27,28,29,30 Elevated sugar consumption contributes to weight gain, which can have adverse health effects and increase the risk of high blood pressure, high cholesterol and type 2 diabetes. Overconsumption of added sugar not only contributes to the aforementioned health risks, but also increases the risk for cardiovascular disease-related death. In fact, according to a study published in JAMA Internal Medicine, people who consumed 17 to 21 percent of daily calories from added sugar had a 38 percent higher risk of dying from cardiovascular disease than those who consumed 8 percent of daily calories from added sugar.31
Minimizing the consumption of added sugars is a significant public health priority and is particularly salient for the estimated 1 million New York City residents with type 2 diabetes. The excess consumption of added sugar among people with diagnosed diabetes or prediabetes can result in elevated blood glucose levels (hyperglycemia) and other significant health complications, such as increased risk of heart attack, stroke, blindness, kidney failure, diabetic coma, nerve damage, and amputations.32,33,34 Furthermore, many patients face barriers in accessing diabetes care, such as mobility issues and lack of financial resources.35,36
Added Sugar in Restaurant Items
Americans eat out more than ever and it is estimated over one-third of calories are consumed away from home.37 Restaurant meals and beverages can be a significant source of added sugars, yet there is often a lack of awareness regarding the amount contained in common menu items at most chain restaurants. When surveyed in April 2021, New Yorkers were only able to correctly identify fewer than half the foods and beverages on a McDonald’s menu that contained more than 50 grams (12 teaspoons) of added sugars.38 It is estimated that the average fast-food combo meal contains 68 grams (~16 teaspoons) of total added sugar and many items served by chain restaurants far exceed the FDA daily recommendation for consumption.39 For example, an order of large baked beans at KFC contains 61 (~15 teaspoons) grams of sugar, a small Coca-Cola from Wendy’s contains 66 grams (~16 teaspoons) of sugar, and an order of french toast with bacon from the Cheesecake Factory contains 115 grams (~28 teaspoons) of sugar.40,41,42 Added sugar menu labeling is supported by a vast majority of New Yorkers43 and will help people make more informed decisions about how much sugar they are putting in their bodies.
Without clear, easy-to-use added sugar content information at the point of ordering, it’s difficult to make informed and healthy choices. Studies have demonstrated that health warning labels prominently placed on packages, or at the point of purchase for sugary products, can impact consumer behavior. A 2021 systematic review and meta-analysis published in the American Journal of Preventive Medicine demonstrated that sugar-sweetened beverage warning labels were effective in dissuading consumers from choosing them.44
It is also important to highlight that many of the chain restaurants that would be impacted by this legislation are disproportionately concentrated in low-income and minority neighborhoods. These businesses contribute to the higher burden of diabetes and diet-related disease in these marginalized communities. “Food Swamp” is a term often used to describe neighborhoods where fast-food chains and ultraprocessed foods inundate healthful alternatives. A study published in 2017 in the International Journal of Environmental Research and Public Health found that “the presence of a food swamp is a stronger predictor of obesity rates than the absence of full-service grocery stores.”45 In another study published in 2019 in the Journal of the Endocrine Society, researchers estimated that adult type 2 diabetes is 2.5 times more prevalent in NYC communities characterized as food swamps compared to areas without fast food.46 It is important that residents have clear information about restaurant food items that exceed the daily recommendation for added sugar and can exacerbate diet-related chronic diseases, such as diabetes.
Addressing the Epidemic of Diet-Related Diseases
New York City has long been a leader in promoting healthy eating among its residents and has launched many initiatives aimed at addressing the epidemic of diet-related chronic diseases. These include updating the NYC Food Standards to require that meals and snacks served at city agencies contain less than 10 percent of calories from added sugars and eliminating sugary beverages from vending machines, the expansion of the Lifestyle Medicine program to more NYC public hospitals, and the expansion of plant-based meals as the primary meal option for patients at all NYC public hospitals.
Int. 687 is not without precedent — In 2006, New York City became an innovator and a leader in combating obesity and diet-related diseases by requiring calorie menu labeling and posting in chain restaurants. The initiative (Regulation 81.50), passed by New York City Board of Health, was the first of its kind in the United States; the rest of the country followed suit less than four years later, and the policy has become a national standard.47 Furthermore, in 2015, New York became the first city to pass a sodium warning bill that requires chain restaurants to put a salt shaker icon next to menu items that contain more than the daily recommended intake of sodium (Regulation 81.49).48
In 2019, The New York City Council passed the Sweet Truth Act, which requires chain restaurants to include high sugar warning labels on prepackaged items. This Act was supported by the Hunter College NYC Food Policy Center as per written testimony from Dr. Platkin on February 27, 2019. The passing of Int. 687 would be an important enhancement to that legislation that requires added sugars warning icons on NYC chain restaurant menu boards and signs for all menu items containing more than an entire days’ worth of added sugars. The expansion of this warning label to all menu items is a critical step in ensuring that people have the information they need to make more informed decisions about how much sugar they are putting in their bodies and is supported by the vast majority of New Yorkers.
Int. 675, which would “require the Department of Health and Mental Hygiene to create a telemedicine accessibility plan to improve the availability and accessibility of portable monitoring devices and telehealth devices for populations that could be better served by telemedicine services,” is a major step toward making diabetes care more accessible, possibly preventing both exorbitant medical expenses and unnecessary suffering as a result of the disease. The COVID-19 pandemic highlighted the mobility needs of many diabetes patients, who are more at risk of poor outcome from COVID-19.49,50 Telemedicine can help both physicians and patients manage diabetes care with services such as remote monitoring of glucose levels, virtual education about managing diabetes, and consultation regarding lifestyle changes.51,52 Research has shown that access to these types of services can improve diabetes outcomes.53,54,55,56
We at the Hunter College New York City Food Policy Center support Int. 687 and Int. 675 and stand ready to help in any way we can to address the growing epidemic of diabetes and diet-related diseases in New York City. Additional recommendations to promote education and increase access to healthy and affordable foods to prevent and treat diet-related chronic diseases are listed below:
- Enhance and advance public awareness of the role of food in relation to the prevention and treatment of diet-related chronic diseases. Public schools should integrate courses into their core programming about basic food, nutrition and agriculture. Healthcare settings and community organizations should provide individuals, caregivers, and family members of those diagnosed with a disease with evidence-based research about the role that diet and nutrition can play in health and disease.
- Mandate ongoing education and training about nutrition and the role of diet in the prevention and treatment of disease within educational curricula for physicians and other health care providers.
- Hospitals should be a model for advancing food as medicine and integrating dietary evidence for the prevention and treatment of disease into institutional practices and programs. Whole-food, plant-forward scratch cooking should be prioritized in all hospital kitchens. Ultra-processed foods, unhealthy fats, and high fructose corn syrup must be banned completely from hospital cafeterias. Hospitals should provide a variety of different meal options for the diverse cultural backgrounds of patients
- Expand city-wide incentive programs for fruits and vegetables to more NYC residents. Nutrition incentive programs increase the purchasing power of low-income residents for fruits and vegetables in retail settings. The City should continue to support programs such as Health Bucks and Get the Good Stuff that provide nutrition incentives to SNAP recipients. In addition, the City should create a program to provide nutrition incentives to low-income households that are ineligible for SNAP (including undocumented immigrants and residents whose income is beyond the threshold of the program but struggle to meet dietary needs) and support their acceptance at a variety of retail food businesses including supermarkets, bodegas, and convenience stores.
- Monitor the nutritional profile of the Emergency Food Program (EFP). Require the monitoring and reporting of nutritional quality of food distributed across the emergency food network in NYC. The nutritional quality of food distributed across the EFP network is a critical metric that should be incorporated into the annual Food Metrics report released by the Mayor’s Office for Food Policy. The City should create a position within the Emergency Food Assistance Program for a dedicated full time staff person to oversee targeted technical assistance and resource allocation to EFPs to improve the nutritional quality of food distribution.
- Improve the nutritional quality and cultural appropriateness of food provided by food assistance programs. The City should allocate additional funding for emergency food providers to distribute fresh produce and accommodate the wide range of cultural and dietary needs of community members.
- Expand and increase access to the Supplemental Nutrition Assistance Program (SNAP). Increase the bonus amounts provided by nutrition incentive programs so that SNAP participants can purchase more fresh, whole foods. Expand SNAP pilots that allow recipients to purchase prepared meals with an emphasis on nutrition as opposed to cost per meal. Provide equipment to retailers to allow them to accept SNAP, eWIC, and other healthy food incentives electronically. Facilitate the expansion of food purchases made with SNAP online and wirelessly.