September 2013, VOLUME132 /ISSUE 3

Striving for Meaningful Policies to Reduce Sugar-Sweetened Beverage Intake Among Young Children

  1. Anisha I. Patel, MD, MSHSa,b and
  2. Lorrene Ritchie, PhD, RDc
  1. aDepartment of Pediatrics, and
  2. bPhilip R. Lee Institute for Health Policy Studies, University of California, San Francisco, California; and
  3. cAtkins Center for Weight and Health, University of California, Berkeley, California
  • preschoolers
  • nutrition
  • obesity
  • policy
  • beverages
  • Abbreviations:
    Child and Adult Care Food Program
    sugar-sweetened beverage
  • A strong evidence base links sugar-sweetened beverage (SSB) intake to obesity in older children and adults.18 In this issue of Pediatrics, DeBoer et al add to the evidence using data from a nationally representative US cohort study to show a relationship between SSB intake and obesity among preschool-age children.9 The authors conclude that “strong consideration should be made toward policy changes leading to decreases in SSB consumption among children.”9 The questions we are now hoping to answer are the following: what policy solutions can curb SSB consumption among our youngest children? Equally important, how can these policies be meaningfully implemented in real-world settings?

    DeBoer et al’s study draws attention to a population of preschool-aged children who are often neglected by current SSB policies. Instituting soda taxes and limiting SSB serving sizes in restaurants have been proposed and attempted.10 Healthy beverage policies have been instituted in workplaces,11,12 and >80% of US school districts have policies prohibiting or restricting student access to SSBs.13 However, policies targeting preschool-aged children remain largely absent.

    There are clear federal policymaking opportunities to reduce SSB consumption among young children. The Child and Adult Food Care Program (CACFP), a US Department of Agriculture administered program that provides meals and snacks to low-income children in child care, provides reimbursement for some beverages served (ie, milk and 100% juice) to ∼3.3 million children in CACFP facilities.14 The 2010 Healthy Hunger-Free Kids Act made positive gains by requiring CACFP facilities to make potable water available throughout the day and limiting milk served to preschoolers to low-fat or skim.15 However, the act did not set limits on SSBs in participating facilities. New CACFP regulations will be released this fall, and pediatricians will have an unprecedented opportunity to influence what beverages are allowed in CACFP facilities.

    Although federal policies are important, their reach is limited. Because CACFP facilities account for only a portion of US child care, local regulations are also needed. However, to date, fewer than a dozen states have legislation restricting SSBs in child care.16,17 Even without governmental regulation, child care facilities can set their own institutional beverage standards through the development of facility-level policies and policy communication in parent handbooks and trainings.

    As we all know, policy implementation is where the rubber meets the road. Indeed, there are often gaps between on-the-book regulations and real-world practices. To narrow such gaps, it is critical to ensure implementation of regulations through training and monitoring of child care providers.18 At the same time, it is also important to implement regulations with the “spirit of the law” as well as the “letter of the law” in mind. Although California has one of the most comprehensive regulations on beverages in child care (ie, no SSBs, no more than 1 daily serving of 100% juice, water availability throughout the day including at meals and snacks, and 1% or skim milk without added sweeteners for children aged ≥2),19 we have found wide variation in regulation implementation. For example, although some facilities satisfy the requirement to have water available by having a sink in the classroom from which children must request a drink when thirsty, others provide water in easily accessible small pitchers with cups at meals and ensure that individual-sized reusable water bottles are available at children’s reach both indoors and outdoors.

    DeBoer et al’s article emphasizes the hazards of the vacuum in SSB policy solutions targeting young children. In addition to a sharper policy focus, complementary strategies should be adopted to ensure effective policy implementation in the preschool years:

    • Widen the SSB policy scope from child care to other community settings. Establish healthy vending standards for parks,20 develop regulations that provide incentives to mobile vendors that serve healthy beverages,21 and make milk or water the default for restaurant kids’ meals.12,22

    • Establish and disseminate best practices for beverages in child care. Compile and disseminate success stories and provide technical assistance to generate more widespread implementation of best practices.23

    • Provide training on beverages to child care providers and children.24 Research suggests that environmental changes coupled with education is necessary for sustained behavior change.25

    • Include actionable limits on SSBs in the Dietary Guidelines for Americans and promote water as the first beverage of choice for thirst. Include water on My Plate materials. Provide concrete messages (ie, limit your child’s sugar drinks to no more than once a week) to help families operationalize recommendations.

    • Develop culturally relevant educational materials and campaigns to reinforce messages provided by clinicians and health educators.24

    • Adopt industry marketing strategies for health promotion. Include the use of recognizable characters to promote intake of water.26 Prohibit marketing of SSBs in all media forms to children.

    To date most SSB policy discussion has neglected the youngest children. Isn’t it time to effect meaningful policies and implementation strategies to curb SSB consumption in our youngest children?


    We thank Dr Laura Schmidt and Sheila Stern for their assistance in editing this manuscript.


      • Accepted June 13, 2013.
    • Address correspondence to Anisha I. Patel, MD, MSPH, MSHS, Department of Pediatrics, and Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco, 3333 California St, Suite 245, Mailbox 0503, San Francisco, CA 94118. E-mail: patela{at}
    • Dr Patel conceptualized the commentary and prepared the first draft; Dr Ritchie helped conceptualize the commentary and reviewed and revised the manuscript; and both authors approved the final manuscript as submitted.

    • Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.

    • FINANCIAL DISCLOSURE: The authors have no financial relationships relevant to this article to disclose.

    • FUNDING: This publication was partially supported by Grant Number K23 HDO67305 from the National Institute for Child Health and Human Development, NIH. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the NIH.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    • COMPANION PAPER: A companion to this article can be found on page 413, and online at