Previously reported national data have indicated an upward trend in consumption of sugar-sweetened beverages among children and adolescents between 1988 and 2004 (1
). However, after the implementation of a policy change in the Boston Public Schools restricting the sale of sugar-sweetened beverages on school grounds, we found a reduction in consumption among Boston students, although national data suggest no change in consumption among high-school aged youth during the same period. The magnitude of the decline in consumption of sugar-sweetened beverages after the policy change in Boston Public Schools corresponds to approximately 45 kcals per day, assuming there are 150 kcals per 12-oz serving (www.pepsiproductfacts.com
). This estimate is commensurate with national estimates of caloric consumption of sugar-sweetened beverages consumed by youth during school (approximately 42.5 kcals/d [1
]), suggesting that the observed decline in caloric intake could plausibly be accounted for by the elimination of opportunity for consumption of sugar-sweetened beverages during school. Boston's results also suggest that youth may not compensate for in-school restrictions on sugar-sweetened beverages by increasing consumption outside of school.
Reductions in consumption of sugar-sweetened beverages, if maintained over time and not compensated for by an increase in other dietary intake, could have substantial health impact. A 45 kcal reduction in daily energy consumption could eliminate 25% to 40% of the total excess calories, or "energy gap" (110 kcals-165 kcals/day), that is attributed to increasing average body weight among US children (19
). National data that document changes in drinking patterns suggest that replacing all sugar-sweetened beverages with water among youth could result in an average reduction in total energy intake of 235 kcals/day (20
), and 1 study has documented a significant reduction in obesity among elementary school students after an intervention provided water fountains in schools (21
Boston's success highlights the importance of implementing comprehensive policies and strategies to restrict the sale of sugar-sweetened beverages in all school settings (11
) in conjunction with promoting reductions in consumption of sugary drinks among young people. The passage of the Boston Public Schools beverage policy was the beginning of more widespread focus on promoting more healthful foods and beverages in Boston and Boston schools. For example, further initiatives included the implementation of nutrition-related curricula in middle and primary schools and interdepartmental committees and collaborations charged with monitoring implementation and acceptance of related policy guidelines. Awareness-raising activities in the Boston Public Schools system included a presentation of the new policy guidelines to principals before implementation, parent workshops on healthful snack choices, dissemination of pamphlets to teachers and school staff detailing alternatives for fundraising, and a brochure for school administrators and teachers entitled Healthy Beverages and Snack News
. Boston city officials also negotiated new procurement contracts with vendors who would supply the new more healthful options to schools, and school vending machines were stocked with water and 100% juice instead of sugar-sweetened beverages.
Nationally, the sales to schools of beverage products that meet nutrition standards are tracked as part of the 2006 memorandum of understanding (MOU) signed by the Alliance for a Healthier Generation, the American Beverage Association, and 3 major beverage producers (22
). Data from 2004 to 2006-2007 indicate a decline in overall shipment quantities, particularly in full-calorie carbonated drinks (ie, soda), and increases in the proportion of products shipped that were water or other nonsoda drinks that met the MOU nutritional standards (22
). These data also suggest that if schools were to eliminate all sugar-sweetened beverages, the per-student consumption would drop by about 3.5 oz per day, an amount similar to that found in Boston (3.8 oz).
However, although the increased availability of more healthful beverage options in schools is heartening, strong policies and continued implementation and monitoring are still needed. A recent update on beverage shipments by bottlers suggests that in US high schools alone in 2008-2009, 1.2 billion ounces of full-calorie carbonated soft drinks (18.9% of the product mix) and 1.3 billion ounces of sports drinks (19.8% of the product mix) were still available to students (23
). Given the large quantities of sugar-sweetened beverages still available in school settings, continued policy and environmental efforts at the community, state, and national levels may be necessary to promote and encourage more healthful beverage choices for our nation's young people.
Several limitations of this study merit discussion. We analyzed data from a single community. Nutrition education and health promotion activities focused on consumption of sugar-sweetened beverages separate from the policy change in Boston may play a role in the observed decline in overall consumption of sugar-sweetened beverages. Potentially, those community and school-based education and awareness-raising activities in Boston may have increased student knowledge about consumption of sugar-sweetened beverages, thus contributing to the observed effects that we associate with the policy change. However, school-based education and awareness activities can be considered part of a comprehensive policy implementation strategy, contributing to both policy adherence and compliance within schools. Furthermore, NHANES and Boston Youth Survey estimates of consumption of sugar-sweetened beverages are not directly comparable because of differences in wording and data collection methods. Additionally, accessible alternatives for water in Boston may not be comparable to those in other communities. Although bottled water was available in all Boston schools, a lack of accessible water fountains may have served to increase demand for less-healthful beverages. According to data collected during the 2006-2007 school years, only 14% of Boston Public Schools provided access to public drinking water via water fountains or bubblers (unpublished data, Boston Public Health Commission, obtained October 20, 2008.)
Data from Boston youth indicate that significant reductions in sugar-sweetened beverage intake coincided with a policy change that restricted the sale of sugar-sweetened beverages in public high schools. Because no national evidence has been found for change in consumption of sugar-sweetened beverages among same-aged youth, such policy changes may be promising strategies to reduce unnecessary caloric intake.