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Online ordering for fast food inconsistent with healthy beverage law, study finds
Lack of specific language for online context makes assessing compliance difficult
Beverages offered on fast-food restaurant websites and platforms such as DoorDash, GrubHub and UberEats often do not adhere to the spirit of California's healthy beverage law for children's meals, according to a new study from University of California researchers.
California's healthy-by-default beverage law (SB1192), which went into effect at the beginning of 2019, requires restaurants to offer only plain or sparkling water with no added sweeteners, unflavored milk, or unflavored non-dairy milk as the default beverage in “kids meals.” The law also requires that menus, menu boards and advertisements for those meals include only approved default options.
The law was passed to address increasing rates of childhood obesity and related chronic diseases, with sugary beverages factoring as a significant contributor to those poor health outcomes.
“Healthy-by-default beverage laws work by making the healthiest choice, the easiest choice for families,” said the study's lead author, Hannah Thompson, senior epidemiologist for the UC Nutrition Policy Institute and assistant adjunct professor at the UC Berkeley School of Public Health. “Drinking sugar-sweetened beverages like sodas has been directly linked to health problems such as Type II diabetes, heart disease and cavities.”
Researchers at the NPI – a program of UC Agriculture and Natural Resources – found that most fast-food restaurants serving low-income census tracts did not offer beverages online in a way that is consistent with SB1192. The study focused on those neighborhoods because children from low-income families consume sugar-sweetened beverages in greater quantities, likely exacerbating health disparities.
Published online in the journal Public Health Nutrition, the study looked at a random sample of 254 “quick service restaurant” sites and collected observations from their restaurant-specific websites and three of the most popular online platforms that deliver their menu items – DoorDash, GrubHub and UberEats.
Researchers developed four increasingly restrictive criteria – incorporating beverage availability, upcharges and presentation of beverage options – to assess the implementation of SB1192 in these online ordering contexts. Half of their observations met their most lenient criteria, while less than 6% were consistent with their most restrictive – findings that Thompson called “discouraging.”
“It means families have to work harder to make the healthiest drink choices for their children,” she said. “This also means the law is likely not nearly as successful as it could be in its intent to help reduce sugary drink consumption by kids.”
The researchers had to create their own criteria for “compliance” with the law because, as written, SB1192 does not specifically mention online ordering, which has become increasingly popular due to the COVID-19 pandemic.
“Part of what makes it hard in the online context is that the law was written using language very specific to the in-restaurant physical space, making interpretation of compliance with the law for meals sold online challenging,” Thompson explained. “I'd love to see amended language in the law specific to meals sold online.”
Thompson also said she would like to see “clear and effective” communication with fast food restaurants and online delivery platforms so that they fully understand the healthy beverage law – as well as the use of a monitoring system that could help ensure compliance.
“Laws, which target system-level changes, are one of the most important public health tools we have to reduce sugary drink consumption and improve health for youth of all backgrounds,” she said. “But laws are only as strong as the structures in place to ensure their successful implementation.”
The other NPI-affiliated authors of the study are Senior Evaluators Anna Martin and Ron Strochlic, Evaluation Associate Sonali Singh, and Associate Director of Research Gail Woodward-Lopez, the principal investigator.
Removing sodas for sale at UCSF helps cut sugar consumption and improve health
A study of the first University of California campus (UC San Francisco) to ban the sale of soda on campus has shown that employees reduced their consumption by nearly 50 percent. UCSF staff who took part in the study also reduced their waist measurements and weight.
“This was not a ban on the consumption of sugared beverages,” emphasized co-lead author Laura Schmidt, PhD, MSW, MPH, UCSF professor in the Philip R. Lee Institute for Health Policy Studies. “This was a ban on sales on sugary beverages in vending machines, break rooms and cafeterias...People could still bring them from home or buy them off campus.”
The study was published Oct. 28, 2019, in the Journal of the American Medical Association, Internal Medicine.
California Assembly Member Richard Bloom (D–Santa Monica) noted the importance of workplace and governmental restrictions on soda sales while communities are prohibited from establishing local soda taxes for the next 12 years. In June 2018, the beverage industry strong-armed the California Legislature and Governor into enacting a “preemption” law that prohibits communities from passing local soda taxes.
“Workplace restrictions enable communities to take charge of their own health as we build momentum to pass AB 138, my bill that establishes a statewide soda tax that will fund prevention efforts. The bill will reduce soda consumption and generate positive health outcomes in impacted communities, where most needed, just like the UCSF effort,” Bloom said.
Lorrene Ritchie, UC Cooperative Extension specialist and director of the UC Nutrition Policy Institute, which conducts nutrition research to strengthen public policy, commented: “I am so impressed with both UCSF's sales ban and this very well-done study. Sodas are such a huge contributor to our obesity crisis that it is heartening to recognize a solution that any employer can adopt to help people improve their lives.”
Speaking of the UCSF study, lead author Elissa Epel, PhD, UCSF professor of psychiatry and director of the UCSF Aging, Metabolism, and Emotions Center, said: “This shows us that simply ending sales of sugary drinks in the workplace can have a meaningful effect on improving health in less than one year. There is a well-known pathway from soda to disease. High sugar intake leads to abdominal fat and insulin resistance, which are known risk factors for diabetes, heart disease, cancer and even dementia. Recent studies have also linked sugar intake to early mortality.”
Soda tax advocates ride a political roller-coaster
When Genoveva Islas was 12 years old, she was responsible for giving insulin injections to her diabetic tia, her aunt.
“Tia lost her toes, lost her leg, lost her life,” Islas said. “This is a very important fight.”
Islas is director of Cultiva La Salud in Fresno, which works to address poor nutrition and physical inactivity in the San Joaquin Valley. The fight Islas referred to is the “soda wars,” a battle to reduce the amount of sugar-sweetened beverages (SSBs) consumed by Americans. SSBs are the single most significant source of sugar in Americans' diets, amounting to nearly half of sugar intake. They have been unequivocally linked to increases in obesity, diabetes, heart disease, liver disease, tooth decay and some cancers.
Islas talked about the tragic fate of her tia at the July 2019 California Obesity Conference in Anaheim, where 1,025 public health, nutrition, science and political leaders convened to share strategies for overcoming the childhood obesity crisis in the United States. She was part of a panel on taxing sugary drinks to reduce SSB consumption and fund community health programs.
“I'm here because I believe health is a right, not a luxury,” Islas said. “A soda tax is a fight for the community I love.”
“I say regressive is the incidence of diabetes in my community, the incidence of heart disease in my community,” Islas said. “The California Central Valley has the highest rates of drinking water violations. Bottled water is costly. People are choosing sugar-sweetened beverages when it is the most affordable choice for them.”
Money raised by the soda tax, Islas continued, could support water quality improvements and encourage the public to drink free and safe tap water.
California Assemblymember Richard Bloom (D-Santa Monica), who has proposed soda tax legislation several times, was also on the soda tax panel.
“The soda industry has poured a huge amount of money toward lobbying in Sacramento against soda restriction laws,” he said.
Bloom suggested that soda tax proponents be clear about the implications of childhood obesity and associated diseases when working to implement soda tax laws.
“Words like ‘epidemic' and ‘crisis' are used so much, they start to lose their meaning,” Bloom said. “We have a lot of statistics on the science of sugary drinks, but we don't talk about the misery this visits upon people and families and communities – amputations, heart disease, cancer. We need to start telling those stories viscerally.”
Kenneth Hecht, director of policy at UC's Nutrition Policy Institute, moderated the panel discussion. He said that a soda tax is the most cost-effective intervention to reduce soda consumption. It has been implemented and studied in Berkeley, Calif., where voters in 2014 passed a local initiative to tax soda and other sugar-sweetened beverages 2 cents per ounce. Three years later, residents reported drinking 52 percent fewer servings of sugary drinks than they did before the tax was imposed.
“Soda taxes work,” said Kristine Madsen, director of the Berkeley Food Institute and professor at UC Berkeley School of Public Health, who evaluated the Berkeley soda tax and also spoke at the conference.
The bulk of Berkeley's soda tax revenue is dedicated to supporting nutrition education and gardening programs in schools and allocated to local organizations working to encourage healthier behaviors in Berkeley.
San Francisco, Oakland and Albany also passed soda taxes. Other communities were planning to put soda tax initiatives on the ballot, but were stymied by a preemptive strike waged by the soda industry. In June 2018, the California Legislature passed a bill to preempt any new local beverage or food taxes until 2031. According to Assemblymember Bloom, beverage companies spent millions to get an initiative on the ballot that would have prevented local communities from raising taxes without a two-thirds vote, up from 55% of the vote currently needed. They offered to drop the initiative if the California Legislature would impose a moratorium on local soda taxes.
Bloom called the preemption a “disgusting tactic.”
“We had to capitulate to that to protect our local governments,” Bloom said. “It was never a sprint to address soda tax, but now it's become a marathon.”
Public health activists were also outraged.
“If you have enough money, you can put anything on the ballot and use that to extort lawmakers to get what you want,” said Mark Pertschuk, director of Grassroots Change and a conference speaker. “This is a war on local democracy. We need to educate people on what preemption is.”
“It's the same as being tobacco free and drug free,” he said.
One public organization leading the way is UC San Francisco (UCSF), which employs 22,000 staff, academics and medical professionals. In 2015, all its campuses and buildings removed sugar-sweetened beverages from food service outlets and vending machines as part of its Healthy Beverage Initiative. Laura Schmidt, professor in the Institute for Health Policy Studies at UCSF, discussed the ban at the Childhood Obesity Conference.
“When you live in a saturated environment, where it's always in reach, that makes it difficult to say no,” Schmidt said. “We have to change the environment. All effective solutions follow the iron law of public health. If you reduce availability of harmful substances in the environment, you will reduce consumption.”
At the culmination of his Childhood Obesity Conference talk, Bloom announced the recent formation of Californians for Less Soda, a new coalition of public health and health equity advocates and health professionals aligned to decrease consumption of sugar-sweetened beverages in California through effective policies.
Beverage industry using defensive tactics to fight soda tax initiatives
The beverage industry is recruiting low-income and minority groups to help share a message aimed at tanking soda-tax measures in Oakland and San Francisco, reported Winston Cho in the East Bay Express.
The industry has poured in $13 million to fight Oakland's Measure HH and San Francisco's Proposition V, the story said. The groups supporting the measures have received contributions of nearly $4 million, making Measure HH one of Oakland's best-funded initiatives ever.
The American Beverage Association is positioning the tax measures as "grocery taxes," saying that low-income consumers will bear the brunt.
"I think the money invested, in addition to the framing — which is specifically not mentioning sugary beverages — suggests that there's a lot of defense in their offense," said Wendi Gosliner, policy researcher at the UC Nutrition Policy Institute.
The Nutrition Policy Institute is a UC Agriculture and Natural Resources program that conducts and evaluates research related to the impact of nutrition and physical activity on public health.
Patricia Crawford, senior director of research at the Nutrition Policy Institute, told the reporter that justifying the soda tax to the low-income community in Berkeley was an essential part of getting it passed in that community two years ago. NPI hosted multiple town halls when that tax was on the ballot. They invited professors, doctors, and health-care professionals to address the community's concerns.
"People think of soda as just another candy or food, and it isn't," Crawford said. "[The negative impact on public health] is just too costly ... for us to ignore."
In an article Crawford wrote for the UC Food Blog, she reflected on recent research that showed the Berkeley soda tax successfully reduced consumption of sugar-sweetened beverages while raising funds to promote health and wellness activities in Berkeley schools.
"The Bay Area has long been an early adopter of many important ideas, initiating movements that have spread across the country. Will Oakland, Albany and San Francisco follow Berkeley's lead to a healthier future for their communities?" Crawford wrote.
UC CalFresh nutrition educator Nancy Zumkeller shows the amount of sugar in a 32-ounce soda.
Merits of the proposed soda tax
Two years ago, Berkeley voters approved the first soda tax in the country. Folks in Berkeley pay a penny-per-ounce tax on soda and other sugary drinks including sports drinks, energy drinks, bottled sweet tea and coffee drinks. Tax revenues from the first year totaled approximately $1.4 million dollars.
I serve as a member of the Berkeley Sugar-Sweetened Beverage Product Panel of Experts Commission appointed by the City Council. This group is tasked with advising City Council on measures the Council can take to reduce sugar-sweetened beverage consumption and the health impacts of sugar-sweetened beverage consumption in Berkeley.
So far, the City Council has allocated a total of $2 million toward reducing sugar-sweetened beverage consumption and their harmful health impacts. At the recommendation of the experts panel, Berkeley has funded health and wellness activities in Berkeley schools through Berkeley Unified School District's cooking and gardening programming, and a variety of strategies by community agencies to educate residents and increase healthy beverage environments in the city.
Those of us working in the area of nutrition science know that reducing consumption of sugar-sweetened beverages is the most effective way to reduce rates of obesity, diabetes and related health conditions. The greatest source of sugar in the diets of children is sugar-sweetened beverages.
We also now know that the Berkeley tax to date has been a spectacular success. A study published in August by UC Berkeley scientists shows a 21 percent drop in sugar-sweetened beverage consumption in Berkeley's low-income neighborhoods. In comparison, low-income neighborhoods saw a 4 percent increase in sugar-sweetened beverage consumption over the same periodin San Francisco, where a soda tax was defeated in 2014, and in Oakland, which also doesn't currently have a soda tax. The American Beverage Association, which has spent millions of dollars in an effort to defeat various soda tax proposals, opposes soda-tax ballot measures in our communities, and is using advertising campaigns and door-to-door canvassing that spread carefully crafted and misleading messages to voters.
The Bay Area has long been an early adopter of many important ideas, initiating movements that have spread across the country. Will Oakland, Albany and San Francisco follow Berkeley's lead to a healthier future for their communities?
