POLICY STATEMENT Soft Drinks in Schools Committee on School Health

This statement is intended to inform pediatricians and other health care professionals, parents, superintendents, and school board members about nutritional concerns regarding soft drink consumption in schools. Potential health problems associated with high intake of sweetened drinks are 1) overweight or obesity attributable to additional calories in the diet; 2) displacement of milk consumption, resulting in calcium deficiency with an attendant risk of osteoporosis and fractures; and 3) dental caries and potential enamel erosion. Contracts with school districtsfor exclusive soft drink rights encourage consumption directly and indirectly. School officials and parents need to become well informed about the health implications of vended drinksin school before making a decision about student access to them. A clearly defined, district-wide policy that restricts the sale of soft drinks will safeguard against health problems as a result of overconsumption.

Overweight Overweight is now the most common medical condition of childhood, with the prevalence having doubled over the past 20 years. Nearly 1 of every 3 children is at risk of overweight (defined as body mass index [BMI] between the 85th and 95th percentiles for age and sex), and 1 of every 6 is overweight (defined as BMI at or above the 95th percentile).1 Complications of the obesity epidemic include high cholesterol, high blood pressure, type 2 diabetes mellitus, coronary plaque formation, and serious psychosocial implications. 2–6 Annually, obesity-related diseases in adults and children account for more than 300 000 deaths and more than $100 billion per year in treatment costs.7–9 Soft Drinks and Fruit Drinks In the United States, children’s daily food selections are excessively high in discretionary, or added, fat and sugar.10–15 This category of fats and sugars accounts for 40% of children’s daily energy intake.10 Soft drink consumers have a higher daily energy intake than nonconsumers at all ages.16 Sweetened drinks(fruitades, fruit drinks, soft drinks, etc) constitute the primary source of added sugar in the daily diet of children.17 High-fructose corn syrup, the principle nutrient in sweetened drinks, is not a problem food when consumed in smaller amounts, but each 12-oz serving of a carbonated, sweetened soft drink contains the equivalent of 10 teaspoons of sugar and 150 kcal. Soft drink consumption increased by 300% in 20 years,12 and serving sizes have increased from 6.5 oz in the 1950s to 12 oz in the 1960s and 20 oz by the late 1990s. Between 56% and 85% of children in school consume at least 1 soft drink daily, with the highest amounts ingested by adolescent males. Of this group, 20% consume 4 or more servings daily.16 Each 12-oz sugared soft drink consumed daily has been associated with a 0.18-point increase in a child’s BMI and a 60% increase in risk of obesity, associations not found with "diet" (sugar-free) soft drinks.18 Sugar-free soft drinks constitute only 14% of the adolescent soft drink market.19 Sweetened drinks are associated with obesity, probably because over consumption is a particular problem when energy is ingested in liquid form20 and because these drinks represent energy added to, not displacing, other dietary intake.21–23 In addition to the caloric load, soft drinks pose a risk of dental caries because of their high sugar content and enamel erosion because of their acidity.24 Calcium Milk consumption decreases as soft drinks become a favorite choice for children, a transition that occurs between the third and eighth grades.12,15 Milk is the principle source of calcium in the typical American diet.11 Dairy products contain substantial amounts of several nutrients, including 72% of calcium, 32% of phosphorus, 26% of riboflavin, 22% of vitamin B12, 19% of protein, and 15% of vitamin A in the US food supply.25 The percent daily value for milk is considered either "good" or "excellent" for 9 essential nutrients depending on age and gender. Intake of protein and micronutrients is decreased in diets low in dairy products.19,26 The resulting diminished calcium intake jeopardizes the accrual of maximal peak bone mass at a critical time in life, adolescence.27 Nearly 100% of the calcium in the body resides in bone.27 Nearly 40% of peak bone mass is accumulated during adolescence. Studies suggest that a 5% to 10% deficit in peak bone mass may result in a 50% greater lifetime prevalence of hip fracture,28 a problem certain to worsen if steps are not taken to improve calcium intake among adolescents.

Soft drinks and fruit drinks are sold in vending machines, in school stores, at school sporting events, and at school fund drives. "Exclusive pouring rights" contracts, in which the school agrees to promote one brand exclusively in exchange for money, are being signed in an increasing number of school districts across the country,30 often with bonus incentives tied to sales.31 Although they are a new phenomenon, such contracts already have provided schools with more than $200 million in unrestricted revenue. Some superintendents, school board members, and principals claim that the financial gain from soft drink contracts is an unquestioned "win" for students, schools, communities, and taxpayers.31,32 Parents and school authorities generally are uninformed about the potential risk to the health of their children that may be associated with the unrestricted consumption of soft drinks. The decision regarding which foods will be sold in schools more often is made by school district business officers alone rather than with input from local health care professionals. Subsidized school lunch programs are associated with a high intake of dietary protein, complex carbohydrates, dairy products,fruits, and vegetables.16 The US Department of Agriculture, which oversees the National School Lunch Program, is concerned that foods with high sugar content (especially foods of minimal nutritional value, such as soft drinks) are displacing nutrients within the school lunch program, and there is evidence to support this.26 There are precedents for using optimal nutrition standards to create a model district-wide school nutrition policy,33 but this is not yet a routine practice in most states. The discussion engendered by the creation of such a policy would be an important first step in establishing an ideal nutritional environment for students.

Pediatricians should work to eliminate sweetened drinks in schools. This entails educating school authorities, patients, and patients’ parents about the health ramifications of soft drink consumption. Offerings such as real fruit and vegetable juices, water, and low-fat white or flavored milk provide students at all grade levels with healthful alternatives. Pediatricians should emphasize the notion that every school in every district shares a responsibility for the nutritional health of its student body. 2. Pediatricians should advocate for the creation of a school nutrition advisory council comprising parents, community and school officials,food service representatives, physicians, school nurses, dietitians, dentists, and other health care professionals. This group could be one component of a school district’s health advisory council. Pediatricians should ensure that the health and nutritional interests of students form the foundation of nutritional policies in schools. 3. School districts should invite public discussion before making any decision to create a vended food or drink contract. 4. If a school district already has a soft drink contract in place, it should be tempered such that it does not promote over consumption by students. o Soft drinks should not be sold as part of or in competition with the school lunch program, as stated in regulations of the US Department of Agriculture.34 o Vending machines should not be placed within the cafeteria space where lunch is sold. Their location in the school should be chosen by the school district, not the vending company. o Vending machines with foods of minimal nutritional value, including soft drinks, should be turned off during lunch hours and ideally during school hours. o Vended soft drinks and fruit-flavored drinks should be eliminated in all elementary schools. o Incentives based on the amount of soft drinks sold per student should not be included as part of exclusive contracts. o Within the contract, the number of machines vending sweetened drinks should be limited. Schools should insist that the alternative beverages listed in recommendation 1 be provided in preference over sweetened drinks in school vending machines. o Schools should preferentially vend drinks that are sugar-free or low in sugar to lessen the risk of overweight. 5. Consumption or advertising of sweetened soft drinks within the classroom should be eliminated.