Policy Statement

Pediatrics

Volume 113, Number 1

January 2004, pp 152-154

Soft Drinks in Schools

AMERICAN ACADEMY OF PEDIATRICS

Policy Statement

Organizational Principles to Guide and Define the Child Health Care Systemand/or Improve the Health of All Children

Committee on School Health

ABSTRACT. This statement is intended to inform pediatricians and otherhealth care professionals, parents, superintendents, and school board membersabout nutritional concerns regarding soft drink consumption in schools.Potential health problems associated with high intake of sweetened drinks are1) overweight or obesity attributable to additional calories in the diet; 2)displacement of milk consumption, resulting in calcium deficiency with anattendant risk of osteoporosis and fractures; and 3) dental caries andpotential enamel erosion. Contracts with school districts for exclusive softdrink rights encourage consumption directly and indirectly. School officialsand parents need to become well informed about the health implications ofvended drinks in school before making a decision about student access to them.A clearly defined, district-wide policy that restricts the sale of soft drinkswill safeguard against health problems as a result of overconsumption.

BACKGROUND AND INFORMATION
Overweight

Overweight is now the most common medical condition of childhood, with theprevalence having doubled over the past 20 years. Nearly 1 of every 3 childrenis at risk of overweight (defined as body mass index [BMI] between the 85th and95th percentiles for age and sex), and 1 of every 6 is overweight (defined asBMI at or above the 95th percentile).1 Complications of the obesityepidemic include high cholesterol, high blood pressure, type 2 diabetesmellitus, coronary plaque formation, and serious psychosocial implications.2-6Annually, obesity-related diseases in adults and children account for more than300 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 highin discretionary, or added, fat and sugar.10-15 This category offats and sugars accounts for 40% of children's daily energy intake.10Soft drink consumers have a higher daily energy intake than nonconsumers at allages.16 Sweetened drinks (fruitades, fruit drinks, soft drinks, etc)constitute the primary source of added sugar in the daily diet of children.17High-fructose corn syrup, the principle nutrient in sweetened drinks, is not aproblem food when consumed in smaller amounts, but each 12-oz serving of acarbonated, sweetened soft drink contains the equivalent of 10 teaspoons ofsugar and 150 kcal. Soft drink consumption increased by 300% in 20 years,12and serving sizes have increased from 6.5 oz in the 1950s to 12 oz in the 1960sand 20 oz by the late 1990s. Between 56% and 85% of children in school consumeat least 1 soft drink daily, with the highest amounts ingested by adolescentmales. Of this group, 20% consume 4 or more servings daily.16

Each 12-oz sugared soft drink consumed daily has been associated with a0.18-point increase in a child's BMI and a 60% increase in risk of obesity,associations not found with "diet" (sugar-free) soft drinks.18Sugar-free soft drinks constitute only 14% of the adolescent soft drink market.19Sweetened drinks are associated with obesity, probably because overconsumptionis a particular problem when energy is ingested in liquid form20 andbecause these drinks represent energy added to, not displacing, other dietaryintake.21-23 In addition to the caloric load, soft drinks pose arisk of dental caries because of their high sugar content and enamel erosionbecause of their acidity.24

Calcium

Milk consumption decreases as soft drinks become a favorite choice forchildren, a transition that occurs between the third and eighth grades.12,15Milk is the principle source of calcium in the typical American diet.11Dairy 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 Thepercent 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 dairyproducts.19,26 The resulting diminished calcium intake jeopardizesthe accrual of maximal peak bone mass at a critical time in life, adolescence.27Nearly 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 lifetimeprevalence of hip fracture,28 a problem certain to worsen if stepsare not taken to improve calcium intake among adolescents.29

STATEMENT OF PROBLEM

Soft drinks and fruit drinks are sold in vending machines, in school stores,at school sporting events, and at school fund drives. "Exclusive pouringrights" contracts, in which the school agrees to promote one brandexclusively in exchange for money, are being signed in an increasing number ofschool districts across the country,30 often with bonus incentivestied to sales.31 Although they are a new phenomenon, such contractsalready have provided schools with more than $200 million in unrestrictedrevenue.

Some superintendents, school board members, and principals claim that thefinancial gain from soft drink contracts is an unquestioned "win" forstudents, schools, communities, and taxpayers.31,32 Parents andschool authorities generally are uninformed about the potential risk to thehealth of their children that may be associated with the unrestrictedconsumption of soft drinks. The decision regarding which foods will be sold inschools more often is made by school district business officers alone rather thanwith input from local health care professionals.

Subsidized school lunch programs are associated with a high intake ofdietary protein, complex carbohydrates, dairy products, fruits, and vegetables.16The US Department of Agriculture, which oversees the National School LunchProgram, is concerned that foods with high sugar content (especially foods ofminimal nutritional value, such as soft drinks) are displacing nutrients withinthe school lunch program, and there is evidence to support this.26

There are precedents for using optimal nutrition standards to create a modeldistrict-wide school nutrition policy,33 but this is not yet aroutine practice in most states. The discussion engendered by the creation ofsuch a policy would be an important first step in establishing an idealnutritional environment for students.

RECOMMENDATIONS

  1. 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 overconsumption by students.
  5. Consumption or advertising of sweetened soft drinks within the classroom should be eliminated.

COMMITTEE ON SCHOOL HEALTH,2002-2003

Howard L. Taras, MD, Chairperson

Barbara L. Frankowski, MD, MPH

Jane W. McGrath, MD

Cynthia J. Mears, DO

*Robert D. Murray, MD

Thomas L. Young, MD

LIAISONS

Janis Hootman, RN, PhD

  National Association ofSchool Nurses

Janet Long, MEd

  American School HealthAssociation

Jerald L. Newberry, MEd

  National EducationAssociation, Health Information

Mary Vernon-Smiley, MD, MPH

  Centers for DiseaseControl and Prevention

STAFF

Su Li, MPA

*Lead author

REFERENCES

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  34. National School Lunch Program Regulations. 7 CFR §210.11 (2002). Competitive food services

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All policy statements from the AmericanAcademy of Pediatrics automatically expire 5 years after publication unlessreaffirmed, revised, or retired before that time.

Copyright © 2004 by the American Academy ofPediatrics. No part of this statement may be reproduced in any form or by anymeans without prior written permission from the American Academy of Pediatricsexcept for one copy for personal use.

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