Challenging Dogma - Fall 2011

Monday, December 19, 2011

Why Banning Sugar-Sweetened Beverages in Schools Has a Limited Impact on Beverage Consumption and Obesity among Children and Adolescents – Christina B

According to the Centers for Disease Control (CDC), about 17 percent of children in the United States, ages two through nineteen years, are obese (1). This alarming percentage is one reason why obesity has become one of the top ten public health concerns among children today. In fact, many people believe that childhood obesity can be considered an epidemic, not only in the United States but worldwide. This epidemic is not only due to the high percentage of obesity but the three-fold increase we have seen over the past thirty years. In addition, childhood obesity has become a significant financial burden associated with 9.1 percent of all medical costs in the United States (2).
There are many adverse health effects associated with obesity and children who are overweight are at risk of developing many serious chronic illnesses including cardiovascular disease, Type 2 diabetes, high blood pressure, and high cholesterol. Children can also develop serious social and emotional problems such as low self-esteem and depression (3). In addition, these children run the risk of carrying these conditions into adulthood. According to one study, 25 percent of obese adults were overweight as children (4). Another study found that approximately 80 percent of children who were overweight at 10 to 15 years of age were obese as adults at 25 years of age (5).
Although genetics and hormonal disorders are two important causes of childhood obesity, they are only a small part of the complex array of contributing factors. Lack of physical activity, sedentary behavior, and poor eating habits are considered the major reasons for excess weight among children (6). Other factors that have been shown to significantly increase the risk of childhood obesity are low socioeconomic status and environmental causes. Children from low-income families are at greater risk of becoming obese because their families often live in areas that do not provide safe public recreational areas where they can take part in physical activity (7). These families also lack access to affordable healthy food options (8).
The staggering statistics are hard to refute and have promoted various obesity treatment and prevention programs throughout the years. One strategy that has been increasing in popularity is school based policies banning Sugar Sweetened Beverages (SSBs). These policies are based on the understanding that school environmental factors greatly contribute to poor dietary habits among children and adolescents, leading to higher rates of obesity among this population. Since soda and other sweetened beverages are associated with excess energy intake and increased weight gain, simply banning these products will easily reduce exposures to unhealthy behaviors and subsequent health risks.
Sugar sweetened beverage bans in schools are a passive approached which does not require students to take an active role in changing their behaviors. These policies vary in severity, are in many cases completely voluntary, and are not enforced by government or local regulations. One example of an implemented policy, that was put in motion by the American Beverage Industry, involved banning soda, diet soda, or sugary drinks in elementary schools, selling soda in middle school only after school hours, and limiting the quantity of soda to no more than half of the contents of high school vending machines (9). Other policies have gone even further by banning all SSBs. For the purpose of these cases, sugar sweetened beverages (SSBs) are defined as “regular soda, fruit drinks, sweetened ice teas, sports drinks, and other sweetened beverages with added sugar or high-fructose corn syrup.” (10)
These school policies have been embraced by parents and health professionals because of their success in decreasing students’ exposure to unhealthy SSBs. However, it is a flawed initiative that has no effect on the consumption rates of SSBs among children and adolescents. In fact, 85 percent of students reported consuming an SSB at least once in the past seven days, regardless of whether their school had implemented a beverage ban. Thirty three to 36 percent of students reported daily consumption (11).
After evaluating this strategy, three main flaws emerge; there is no effort to include student nutrition education in any of these policies, policies that ban only soda are not preventing students from having access to other SSBs, and the policies that do ban all SSBs do not address the fact that students have access to these products outside of school.
Disregard for Education and Social Norms
In many public health initiatives, basic education of the risks and social factors often takes a back seat to straight forward facts and figures. In the case of SSB bans in schools, neither form of education is utilized. The only fact that resonates with this initiative is that increased consumption of SSBs can lead to increased weight gain among children and adolescents (11). More specifically, SSBs contribute on average 224 calories of kids’ total calorie consumption per day (11). Soda alone, accounts for more calories than any other food or beverage among teens between the ages of 14 and 18 years old (11).
Unfortunately, these policies to not include the dietary guidelines, published by the American Heart Association and the Department of Agriculture, which recommends only 4 to 6 ounces of SSBs per day for children between 1 and 6 years of age and 8 to 12 ounces per day for children between 7 and 18 years of age (11). In addition, many school SSB policies do not acknowledge that nutritionists recommend only three beverages for kids; bottled water, 100 percent fruit juice, and milk (12). Although kids are unaware of these facts and are unlikely to be influenced by their strengths, it is important for adults to be aware so that they may implement strategies that successfully address the growing obesity problem.
Lack of education among adults and children also extends to the fact that kids are greatly influenced by social norms and have a distorted conception of the average consumption rates among their peers. This can be illustrated using the law of small numbers which states that individuals have a distorted view of probability and are bad judges of risk (13). In the case of SSB consumption, students estimate that their peers typically consume about 2.64 SSBs per day. In reality, the average self-reported SSB consumption is only 1.49 per day (14). In other words, 76 percent of students overestimate the daily SSB consumption rate among their peers (14). This may suggest that overestimating the average amount of peer SSB consumption may contribute to unhealthy beverage choices, thus increasing the rate of overweight children and adolescents.
The bottom line is that these simplistic policy actions leave students uneducated about the nutritional value of various beverages, the actual sugar sweetened consumption norms among peers, correct information on what is defined as an SSB, and correct SSB portion size. This leaves kids unable to make educated decisions on which products are good for them and which ones are not.
Forgetting the “Soda Without the Bubbles”
Sugar sweetened beverage policies that strictly ban only soda from schools have proven to be a complete failure of the goals set by such initiatives. Studies show that in schools with only a soda ban in place, two-thirds of students still have access to purchasing sugar sweetened beverages (15). This is because the American Beverage Association’s policy only restricts against selling soda in middle and high schools and not against other sweetened beverages such as sports and juice drinks (9).
Therefore, removing only soda from cafeterias and school vending machines does not prevent students from buying other SSBs instead. In fact, students in schools with soda bans still buy and consume SSBs as frequently as their peers in schools where there are no bans at all (11). Ultimately, this policy does not reduce access and consumption of SSBs and is why many types of lemonade, iced tea, flavored fruit drinks, and sports drinks are increasing in number in school vending machines.
This is a failure to correctly and successfully apply the social expectations theory to decrease childhood obesity. The social expectations theory explains that people’s behavior is dictated by social norms. Therefore, by changing social norms you can change peoples’ behaviors and attitudes (16). In the case of soda bans, schools attempt to change the social norms of SSB consumption among children and adolescents by simply changing the policies in schools. However, these policies are too focused on soda and are too limited to completely eliminate exposure to SSBs. In addition, these policies do not extend to other SSB exposures outside of school, which will be discussed in the next section.
In the end, schools with policies that only ban soda are no more successful at reducing kids’ sugar access and consumption than schools that take no action at all. These policies are also giving some students the wrong idea about which drinks are good for them. By restricting only one unhealthy beverage option you create misconceptions about which beverages are healthy for kids and which ones are not.
Sustaining the “Status Quo”
By slightly improving the policies, schools that ban all sugar sweetened beverages are able to successfully decrease students’ access to unhealthy beverage options. However, students’ total consumption of sugar sweetened beverages has not decreased, suggesting that they still have access to SSBs elsewhere. Even though the school environment is healthier, children and adolescents are able to compensate with continued access to banned beverages outside of school through convenient stores, fast food restaurants, and home. In reality the largest source of soft drinks for students is not at school. Instead the greatest source is at students’ homes, followed by restaurants, fast food venues, vending machines, and cafeterias (10).
Similar to school bans on soda only, these stricter polices fail to accurately apply the social expectations theory. Simply banning all SSBs in school is not enough to change the consumption norms among kids who are exposed and have access to the same products outside of school. A more widespread population policy that limits children and adolescents’ access both in and out of school is needed to successfully change these norms.
These policies also fail to correctly and successfully use the psychological reactance theory. This theory explains the effect of threatening or reducing people’s freedom (17). In the case of SSB bans in schools, policies are removing all access to unhealthy beverages which takes away children and adolescents’ right to choose whether or not they want to drink soda and other sugar sweetened beverages. This invokes a reactance that leads these students to seek banned beverages elsewhere.
It is beneficial to remember that like adults, children and adolescents have the ability to make free and informed choices. Since students are exposed to multiple environments, a policy cannot simply remove access in only one area and expect them to refuse temptation in the others. This concept also works in reverse. Studies show that children who have parents that strictly manage their eating habits are found to consume more unhealthy foods. These foods are accessible in schools, restaurants, and other venues outside the home (18).
Change for the Future
These policy failures all boil down to the fact that sugar sweetened beverage bans in schools are just not getting the job done. Although schools may be a large piece of the childhood obesity puzzle they are not the only piece. There are many factors that exist outside of school that also have major effects on the dietary habits of children and adolescents. In order to create a healthier school environment that extends beyond the classroom, more comprehensive laws must be implemented both within and outside of school.
Another important factor that must be kept in mind is the strength that social norms play in the decision making process of both children and adults. The United States is a country where anyone can live the American dream and live the American way of life. The social norm in the United States is that there are no limits to what you can do or have, which encourages people to earn more and consume more. This belief is learned at a very young age and has become projected onto the issue of obesity.
Therefore, a successful campaign must reverse this way of thinking while strengthening the school SSB polices already in place and complementing them with other laws and initiatives outside of the schools. One strategy to achieving this goal is to correctly use the social expectations theory and incorporate it with the social learning theory and the law of small numbers. This campaign will change the social norms among children and adolescents which may lead to improvements in their dietary behaviors, ultimately reducing the prevalence of child obesity.
The Role of Social Expectations Theory
As mentioned earlier, the social expectations theory is concerned with how perceived expectations motivate behavior change. Sugar sweetened beverage policies in schools have poorly exercised this theory, but one way to strengthen these initiatives would be to have all policies ban the availability of all SSBs in school cafeterias and vending machines. In order to support the school policies, population policies such as sweetened beverage taxes and marketing regulations must also be implemented.
The goal of these policies and laws would be to shift from individual risk factors to environmental factors. One great example would be to make water, milk, and 100 percent juice cheaper and all sugar sweetened beverages more expensive. Studies show that as healthy food and beverage prices go down consumption increases. When unhealthy food and beverage prices go up weight levels decrease (19). Since obesity disproportionally affects individuals of lower socioeconomic status, this effort may be a great benefit to a large percentage of high risk children and adolescents.
Incorporating Social Learning Theory and the Law of Small Numbers
Undoubtedly, not everyone will make the dietary changes that are desired. Therefore, it is beneficial to incorporate the social learning theory. The social learning theory emphasizes the importance of observing and modeling in order to change the behaviors, attitudes, and emotional reactions of others (20). Ideally, in the case of using policies and laws to reduce the access and consumption rate of unhealthy beverages, more and more individuals begin to buy and consume healthier food and beverage options. Those that do not will become the minority. Ultimately, by observing others that choose healthier dietary behaviors, these individuals will be influenced to copy what they see around them by changing their behaviors as well.
Nutrition education programs for children and adults would also be a great option for this aspect of the campaign. One example may be a program that could be implemented in the schools. This could be a garden-nutrition enhanced education program, which would be an environmental based learning curriculum that directly exposes kids to fresh fruits and vegetables. It gives students a hands-on experience that produces a sense of ownership and allows them to actually taste various kinds of produce (21).
However, it is extremely important that this program also incorporates the law of small numbers. As mentioned early, this law states that individuals have an incorrect intuition of probability and risk. By showing children and adolescents that their peers only drink 1.49 SSBs per day on average, instead of the 2.64 SSBs per day that they assume their peers drink, they may be encouraged to change their behaviors in order to reflect the actual consumption rate (14).
The Public and Social Agendas
One important aspect to every public health campaign, regardless of the type of initiative being implemented, is that it is on the media agenda. This concept is illustrated by the agenda setting theory which shows that the media agenda dictates the public agenda (22). The United States is a socially connected country that puts a great emphasis on connections and associations. If it is possible to get a public health campaign on the public agenda then everyone will talk about it. If an issue is not on the public agenda, action will not be taken and it is unlikely that the campaign will be successful.
Children are the most vulnerable and easily influenced population group in our society and although there are many health concerns for children these days, obesity has exploded into a major epidemic. There is no doubt that this growing health concern is due to poor diet and lack of exercise and is linked to many chronic health concerns. Child obesity is in no way an easy fix either. There are many layers that must be addressed and no simple solutions to completely rectify the problem. However, these issues can be addressed through various prevention campaigns utilizing the social expectations theory, the social learning theory, and the law of small numbers. With a campaign that uses various policies and initiatives to change the social norm we can address the issue of childhood obesity and not only extend the lives of our children but improve the quality of life for our society’s future adults. 

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