June/July 2021 Issue
Reducing SSB Intake — An Interprofessional Approach
By Christen Cupples Cooper, EdD, RDN
Today’s Dietitian
Vol. 23, No. 6, P. 30
Strategies to Decrease Kids’ Consumption
High intake of added sugars, those not naturally occurring in foods but rather added during processing, elevates the risks of obesity, CVD, hypertension, obesity-related cancers, and dental caries.1,2 Several studies have suggested correlations between sugar intake and increased weight gain.3-6
The 2020–2025 Dietary Guidelines for Americans recommend individual limit intake of added sugars to less than 10% of daily calories. But the National Health and Nutrition Examination Survey 2009–2012 showed that American children and adolescents consumed, on average, 80 g of added sugars per day (16.1% of calorie intake), about one-half of which comprised sugar-sweetened beverages (SSBs), including soft drinks, fruit drinks, sweetened tea and coffee beverages, sports drinks, energy drinks, and flavored milks.2 This is unsurprising given that a single serving of the most popular brands of fruit drinks—CapriSun, Hawaiian Punch, Sunny D, and Minute Maid Lemonade—contains more than 50% of children’s recommended daily limit for added sugars.
Other studies support that consumption of SSBs across all age groups is higher than recommended. In 2011–2014, nearly 63% of children and adolescents consumed at least one SSB daily.7 The 2016 Feeding Infants and Toddlers Study, published in 2018 after analysis, reported that 0.9% of infants aged 0 to 6 months, 8.5% of infants 6 to 12 months, 29.1% of toddlers 12 to 24 months, and 45.5% of toddlers aged 2 to 4 consumed SSBs.8 Pan and colleagues found in their study, published in an April 2014 issue of the FASEB Journal, that obesity rates among children who consumed SSBs during infancy (0 to 12 months) were double those of non-SSB consumers at age 6.
Bleich and Vercammen found in their review of the literature, published in BMC Obesity in February 2018, that SSB intake in toddlers was associated with overweight and obesity, insulin resistance, and dental caries. In a study that compared toddlers who consumed no SSBs with toddlers who consumed two or more SSBs per day, zero consumption was suggested to be protective against obesity.9 Three longitudinal studies and one retrospective study correlated high SSB intake with a higher BMI z-score and increased risk of overweight and obesity in children between the ages of 5 and 7.3,10-12
A study by Han and Powell, published in the Journal of the Academy of Nutrition and Dietetics in January 2013, found that although consumption of soda, the most popular type of SSB, is declining overall, intake of sports drinks and energy drinks among adolescents tripled over the last two decades. In addition, the number of heavy consumers, considered those who drink 500 kcal or more of SSBs per day, was the highest among adolescents and young adults. Also concerning is that an increasing number of younger children are becoming heavy consumers.
A Complex Problem
High SSB intake among children is a complex, multifactorial problem. RDs can help primary care providers learn and understand the social determinants of SSB intake and use them to promote behavior change. A 2014 study by Beck and colleagues suggested that several factors impact parents’ knowledge, attitudes, and behaviors regarding SSBs, including availability, affordability, culture, and children’s and parents’ taste preferences.13 Children from families with lower incomes, or from Latino and Black populations, are more likely to consume SSBs compared with their higher-income, white peers.14,15 These children also are more likely to have overweight or obesity.16
Lower-income parents report a lack of knowledge and familiarity with the health harms of SSBs. A study by Munsell and colleagues of 982 parents, published in Public Health Nutrition in January 2016, found that many believed some SSBs such as flavored waters, fruit drinks, and sports drinks were healthful options for children. Northrup and Smaldone found that many mothers of young children in a low-income, high-risk population selected SSBs over milk or water during a feeding simulation exercise.17
The literature also suggests that a lack of label reading skills is a barrier to parents’ regulation of SSBs, largely because US food labeling regulations permit foods and beverages to be labeled as “natural” or containing “real fruit” even if only a small proportion of their ingredients meet these descriptions. Parents in the Beck and colleagues’ study expressed that many labels appear to convey healthfulness even when a beverage isn’t healthful. Cooper and Northrup found that clients enrolled in WIC believed juice in general to be healthful because the WIC program distributes vouchers for juice. In other words, clients were unaware of the difference between 100% juice and juice drinks.18
In addition, powerful marketing campaigns that promote SSBs sometimes falsely tout these beverages’ nutritional, taste, or lifestyle benefits.19 It’s clear that a complex set of factors—socioeconomic, educational, cultural, and economic—contribute to parents’ provision of and children’s preferences for SSBs.
Nutrition Education for Health Care Professionals
One would expect primary care physicians and dentists to screen children and adolescents for SSB intake because of the potential health harms these beverages pose. However, medical education for physicians, dentists, physician assistants, nurses, and other primary care providers often includes little nutrition education or instruction on SSBs. Given this reality, in addition to limitations on insurance coverage for dietary counseling with RDs, many patients who might otherwise work to prevent overweight and obesity and their comorbidities don’t receive the guidance they need, putting them at risk without preventive care.
The average medical student receives fewer than 25 hours of nutrition education, according to the Harvard T.H. Chan School of Public Health. A study by Antognoli and colleagues, published in Health Promotion and Practice in September 2017, examined the obesity, nutrition, and physical activity didactics offered by family medicine, internal medicine, and OB/GYN residency programs across Ohio. An average of 2.8 hours of this education was offered per year, and only 10 programs (42%) taught techniques for health behavior counseling.
Sullivan conducted a study, published in the Winter 2000 issue of the Journal of Physician Assistant Education, on nutrition education in physician assistant programs across the United States. Sullivan found that while MNT is an essential component of health promotion and disease prevention, there are no specific requirements for nutrition education in physician assistant programs. While 94% of responding physician assistant programs included nutrition education as a curricular component, students received an average of 18 hours over two years. Only 29% of programs provided a separate nutrition education course, with nutrition education most often (64%) integrated into clinical medicine courses. Fifty-eight percent of these courses were taught by RDs.
RDs’ Educational Role
Many dietitians have taken the initiative to educate medical professionals about nutrition and its association with health and chronic disease.
Kay Stearns Bruening, PhD, RDN, FAND, an associate professor of nutrition science & dietetics and director of the Nutrition Assessment, Consultation, & Education Center at Syracuse University, created a Food as Medicine elective course for a neighboring institution, the SUNY Upstate Medical University, in 2019. The course, which covers the Standard American Diet and the dangers of added sugars and SSBs, was filled in the first three hours of registration and accrued a long waiting list. Bruening recognizes physicians’ time crunch and encourages collaboration with other professionals, including RDs, to promote lifestyle behavior changes. She’s pleased that her reach is great when teaching medical and respiratory students about nutrition, since they will see more patients than the average RD.
Jillian Kaye, MS, RDN, an adjunct clinical instructor for dental students in the department of cariology and comprehensive care at New York University College of Dentistry, coteaches two seminars aimed at risk assessment of geriatric patients and gives lectures across numerous courses such as Health Promotion, Pediatric Dentistry, Body and Disease, Precision Medicine, and an introductory nutrition lecture for first-year dental students. She says, “To my knowledge, unlike dental hygiene programs, there’s no required set of nutrition-specific hours in the dental school curriculum that’s mandated for accreditation by the Commission on Dental Accreditation. Good nutrition starts in the mouth. I think interprofessional education opportunities like the job I have are vital to patient care.”
In the July 2019 issue of the Journal of the American College of Nutrition, Cresci and colleagues wrote there’s an urgent need for more nutrition education for primary care providers, given the nation’s upward battle with diet-related chronic conditions, which pose the greatest costs to our health care system. RDs who teach medical, pre–physician assistant, nursing, and continuing education students report several ways RDs can play valuable roles in nutrition education for medical professionals.
Julie Stefanski, MEd, RDN, CSSD, LDN, CDCES, FAND, a spokesperson for the Academy of Nutrition and Dietetics based in York, Pennsylvania, and writer for continuing education company Relias, says, “Effective nutrition education efforts need to go beyond just an update on the evidence behind nutrition recommendations. It’s also vitally important to target interprofessional education efforts that teach health care practitioners how to collaborate on an issue like healthful eating habits. When RDNs provide interprofessional nutrition education and interprofessional continuing education, it doesn’t simply mean that RDNs attend the same grand rounds as other health care providers. True [interprofessional continuing education] means that learning is planned from the beginning with the input of all targeted health care providers, and the education includes ways health care providers can collaborate.”
Kaye adds, “I think the one thing that dental students really understand is the connection between sugar and cavities. However, there sometimes is a lack of understanding of all the places sugar can be in one’s diet. Cavities originate from repeated exposure to an acidic environment in the mouth with bacteria feeding on the sugars we eat. It takes an RD’s expertise to explain to the students that sugar is not just in the classic foods and beverages we think of—candies, cookies, soda—but also can come from frequent snacking of carbohydrate-heavy snacks, sugar-sweetened beverages, [and beverages] considered healthful like 100% fruit juices [which contain only their natural sugars]. I think that dental students come in with only a layperson’s understanding about the connection between nutrition and oral health.
“RDNs are also key in helping students learn how to educate families on the impact that SSBs can have on their oral health and providing an understanding of why someone may be choosing these beverages over water. If dental students can understand why a mom is offering her child fruit juice, they can educate the mom about why fruit juices are not like eating whole fruit and why it is increasing their child’s risk of cavities.”
Annie N. Kirby, PhD, RD, LD, an assistant professor of nutrition at Edward Via College of Osteopathic Medicine in Auburn, Alabama, says, “Most of the students report excitement about the nutrition content in the curriculum. We integrate the nutrition within their clinical medicine subject matter so they see how it should seamlessly flow with patient care. It helps immensely that our institution recognizes the importance of having an RDN teach the content. The students value the expertise and are better able to recognize who they should be utilizing for referrals.”
Kirby believes her osteopathic medicine students learn to ask the right nutrition-related questions but feel less confident educating their patients because they get little experience practicing counseling on these topics. “This is something we are desperately trying to improve within the curriculum,” she says. “Also, inquiring about diet and beverages commonly gets lost in the rest of the information they need to obtain during the patient experience. So, it’s less about them knowing the information and more about them actually applying what they know in the context of the full patient appointment.”
Stefanski says short appointment times in primary care sometimes makes discussing nutrition, and SSBs in particular, nearly impossible. “I think sometimes health care providers are reluctant to even ask about a patient’s diet due to the limited time they’re allotted to spend with an outpatient. Even bringing the subject up can kick off a lengthy discussion a provider might not have the time or accurate knowledge to address.” However, Stefanski emphasizes that this is where an RD can step in and collaborate with a primary care provider to work on the behavioral change issues and offer the nutrition facts patients really need.
According to Kaye, “Dental students value the ability to extract information from patients, whether it be through 24-hour diet recall or motivational interviewing, and then use that information to help motivate their patients to make changes.” She believes that having these skills helps her students feel they’re providing comprehensive and thorough care to their patients beyond the old “drill and fill” style of dentistry.
Protocol and Guidelines
Not only are primary care providers and other health care professionals welcoming and receiving more nutrition education, but those in the field of pediatrics along with other agencies and organizations have taken impressive strides as well.
Bright Futures, a national health promotion and prevention initiative led by the American Academy of Pediatrics and supported by the US Department of Health and Human Services, the Health Resources and Services Administration, and the Maternal and Child Health Bureau, created an evidence-based patient care protocol for pediatricians. The “Bright Futures Guidelines” include a series of questions on eating and oral health that pediatricians can ask during child well-visits from the ages of 1 to 4. The guidelines also provide verbiage about serving 100% juice in a cup rather than a bottle and avoiding serving any juice (100% or otherwise) to children under 6 months. However, the protocol lacks questions that delve into how much and what kinds of beverages parents are serving. Since the complex problem of SSB intake involves not only children but also their parents, family members, friends, childcare providers, and external forces such as advertising, RDs’ nuanced knowledge of SSB choices can play a key role in helping doctors guide patients on this topic.
The Caries Risk Assessment Form, issued by the American Dental Association, contains a series of questions about sugary food and drink intake. “This is intended to be filled in after completion of a 24-hour dietary recall, but students often report that they don’t have enough time during their appointments to devote to it,” Kaye says. “This leaves the students to just ask patients questions. I have heard a student once ask a 6-year-old patient: ‘How much sugar do you eat each day?’ I was shocked by such a vague and leading question. I am continually trying to educate our students about how to properly extract information that’s direct and simple enough for the patient to understand and answer correctly.” Kaye believes RDs can fill the void between patients’ perceptions of grams of sugar and what these amounts of sugar look like in terms of actual food. This can make all the difference in doctors’ understanding patients’ sugar intake, and it allows for clear, actionable recommendations.
A key component of RDs’ instructions for health care professionals is understanding how to use the protocols and tools available to evaluate a patient’s disease risk and use their clinical judgment on whether to refer to an RD.
Value of Nutrition Knowledge Across Disciplines
Nutrition education provided by dietitians can, in many ways, help enhance patient care in terms of protecting young patients from the potential harms of SSBs. According to RDs working in interprofessional capacities, this can be done best by conveying the complexity of the problem to health care students, making them aware of how to look for social determinants of health that may help people change their behavior, such as a perceived threat of chronic disease, for example, and perceived benefits such as feeling better or not gaining weight.
“I hope I’m making our students better dentists when they graduate because they gain a better understanding of the complexities of their patients’ oral and overall health as it relates to nutrition,” Kaye says. “I know I’m a better dietitian because of my opportunity to work alongside them.”
Bruening says the medical students taking her Food as Medicine course consistently rate the course as very important. Whereas most students take the course as seniors, many have expressed interest in taking it during the first year of medical school so they can apply nutrition knowledge throughout their medical education and residency.
As Ellen Mandel, DMH, MPA, MS, PA-C, RDN, CDE, a college professor, says: “RDNs’ knowledge of the science of nutrition is central to disease prevention and health promotion. The RDN’s training in motivational interviewing and cultural aspects of eating are of paramount importance to patient care. Medical providers require varied levels of nutrition knowledge and should learn when the RDN’s expertise is needed and how to secure such assistance.”
— Christen Cupples Cooper, EdD, RDN, is founding chair and an assistant professor of nutrition and dietetics in Pace University’s College of Health Professions in Pleasantville, New York. You can find her at pace.edu/nutrition.
References
1. Hu FB, Malik VS. Sugar-sweetened beverages and risk of obesity and type 2 diabetes: epidemiologic evidence. Physiol Behav. 2010;100(1):47-54.
2. Vos MB, Kaar JL, Welsh JA, et al. Added sugars and cardiovascular disease risk in children: a scientific statement from the American Heart Association. Circulation. 2017;135(19):e1017-e1034.
3. DeBoer MD, Scharf RJ, Demmer RT. Sugar-sweetened beverages and weight gain in 2- to 5-year-old children. Pediatrics. 2013;132(3):413-420.
4. Shefferly A, Scharf RJ, DeBoer MD. Longitudinal evaluation of 100% fruit juice consumption on BMI status in 2–5‐year‐old children. Pediatr Obes. 2016;11(3):221-227.
5. Skinner AC, Ravanbakht SN, Skelton JA, Perrin EM, Armstrong SC. Prevalence of obesity and severe obesity in US children, 1999-2016. Pediatrics. 2018;141(3):e20173459.
6. Skinner AC, Skelton JA. Prevalence and trends in obesity and severe obesity among children in the United States, 1999-2012. JAMA Pediatr. 2014;168(6):561-566.
7. Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among US Youth, 2011-2014. NCHS Data Brief. 2017;(271):1-8.
8. Kay MC, Welker EB, Jacquier EF, Story MT. Beverage consumption patterns among infants and young children (0–47.9 months): data from the Feeding Infants and Toddlers Study, 2016. Nutrients. 2018;10(7):825.
9. Davis JN, Koleilat M, Shearrer GE, Whaley SE. Association of infant feeding a dietary intake on obesity prevalence in low‐income toddlers. Obesity. 2014;22(4):1103-1111.
10. Dubois L, Farmer A, Girard M, Peterson K. Regular sugar-sweetened beverage consumption between meals increases risk of overweight among preschool-aged children. J Am Diet Assoc. 2007;107(6):924-934.
11. Lim S, Zoellner JM, Lee JM, et al. Obesity and sugar‐sweetened beverages in African‐American preschool children: a longitudinal study. Obesity. 2009;17(6):1262-1268.
12. Welsh JA, Cogswell ME, Rogers S, Rockett H, Mei Z, Grummer-Strawn LM. Overweight among low-income preschool children associated with the consumption of sweet drinks: Missouri, 1999–2002. Pediatrics. 2005;115(2):e223-e229.
13. Beck AL, Takayama JI, Halpern-Felsher B, Badiner N, Barker JC. Understanding how Latino parents choose beverages to serve to infants and toddlers. Matern Child Health J. 2014;18(6):1308-1315.
14. Grimes CA, Riddell LJ, Campbell KJ, Nowson CA. Dietary salt intake, sugar-sweetened beverage consumption, and obesity risk. Pediatrics. 2013;131(1):14-21.
15. Kit BK, Fakhouri TH, Park S, Nielsen SJ, Ogden CL. Trends in sugar-sweetened beverage consumption among youth and adults in the United States: 1999–2010. Am J Clin Nutr. 2013;98(1):180-188.
16. Ogden CL, Carroll MD, Lawman HG, et al. Trends in obesity prevalence among children and adolescents in the United States, 1988-1994 through 2013-2014. JAMA. 2016;315(21):2292-2299.
17. Northrup AA, Smaldone A. Maternal attitudes, normative beliefs, and subjective norms of mothers of 2- and 3-year-old children. J Pediatr Health Care. 2017;31(3):262-274.
18. Cooper CC, Northrup A. Understanding attitudes and practices of low-income parents toward sugar-sweetened beverage consumption in preschool-aged children [under review].
19. Harris JL, Romo-Palafox M, Choi YY, Kibwana A; UConn Rudd Center Food Policy & Obesity. Children’s drink FACTS 2019: sales, nutrition, and marketing of children's drinks. http://sugarydrinkfacts.org/resources/FACTS2019.pdf. Published October 2019.