Agenda packet — Santa Cruz City Council, June 25, 2024 (part 5 of 5)

41.13 "Sugar-Sweetened Beverage Product(s)" means a Sugar-Sweetened Beverage and/or a Concentrate.
"Tax Administrator" means the Director of Finance for the City of Santa Cruz or a designee of the Director of Finance.

3.38.025 - EXEMPTIONS
"Sugar-Sweetened Beverage" and “Sugar-Sweetened Beverage Product” shall not include:
1) any beverage that contains less than 40 calories per 12 fluid ounces of beverage; 2) any beverage sold for consumption by infants, which is commonly referred to as "infant formula" or "baby formula," or oral rehydration fluids for children; 3) any beverage for medical use;
4) any beverage designed as supplemental, meal replacement, or sole-source nutrition that includes proteins, carbohydrates, and multiple vitamins and minerals; 5) Milk Products;
6) 100 percent natural fruit or vegetable juice or combination thereof with no added caloric sweetener (e.g., sugar, corn syrup);
7) Any Concentrate that the Consumer directly purchases as a Concentrate and then may combine with other ingredients to create a Sugar Sweetened Beverage; 8) Sweetened medication such as cough syrup, liquid pain relievers, fever reducers, and similar products;
9) Natural or Common Sweeteners, or
10) Any alcoholic beverage.

The Tax shall not apply to:

1. Any Distributor that is not subject to taxation by the City under the laws of the United States or the State of California.

2. The Distribution of any Sugar-Sweetened Beverage Product to a Small Business as defined in this chapter.

3.38.030 - EXCISE TAX
In addition to any other taxes imposed by the City, the City hereby levies a General Tax of two cents ($0.02) per fluid ounce on the Distribution of Sugar-Sweetened Beverage Products in the City.

For the purposes of this chapter, the volume, in ounces, of a Sugar-Sweetened Beverage Product shall be calculated as follows:

1. For a Sugar-Sweetened Beverage, the volume, in fluid ounces, of SugarSweetened Beverages distributed to any Person in the course of business in the City.

2. For Sugar-Sweetened Beverage Products that are Concentrates, the tax shall be

41.14 calculated using the largest volume, in fluid ounces, of Sugar-Sweetened Beverage that could be produced from the Concentrate. In accordance with rules and regulations promulgated by the City pursuant to Section 3.38.040, the largest volume, in fluid ounces, that would typically be produced from the Concentrates shall be determined based on the manufacturer's instructions or, if the Distributor uses that Concentrate to produce a Sugar-Sweetened Beverage, the regular practice of the Distributor.

3. The Tax shall be paid upon the first nonexempt Distribution of a Sugar-Sweetened Beverage Product in the City. To the extent that there is a chain of Distribution within Santa Cruz involving more than one Distributor, the tax shall be levied on the first Distributor subject to the jurisdiction of the City. To the extent the Tax is not paid as set forth above for any reason, it shall be payable on subsequent Distributions and by subsequent Distributors; provided, that the Distribution of Sugar-Sweetened Beverage Products may not be taxed more than once in the chain of commerce.

3.38.040 - ADMINISTRATION OF TAX
It shall be the duty of the Tax Administrator to collect and receive all taxes imposed by this chapter, and to keep an accurate record thereof.

The Tax Administrator is hereby charged with the enforcement of this chapter, except as otherwise provided herein, and may prescribe, adopt, and enforce rules and regulations relating to the administration and enforcement of this chapter. Such rules and regulations shall include, but are not limited to:

1. Clarification regarding the inclusion or exclusion of particular products.

2. The calculation of tax for concentrates based on manufacturer’s instructions or industry practice and the designation of caloric sweeteners.

3. The reexamination and correction of returns and payments, and for reporting.

4. Prescribing the methods, frequency, and schedules for the calculation, collection and payment of the tax.

5. The manner and form in which a Distributor must register with the City, and report and remit the tax.

6. How a Distributor or a Retailer who receives, in the City, Sugar-Sweetened Beverage Product(s) from a Distributor must report to the City the name of that Distributor and the volume of Sugar-Sweetened Beverage Product(s).

7. The documentation to be created or maintained by a Distributor or a Retailer.

8. The administrative process and procedures for any Person against whom a determination is made by the Tax Administrator under this chapter or any Person directly interested in such determination, shall follow to dispute or otherwise challenge a determination, and the form, manner and time within which a determination may be disputed or challenged.

Adoption and implementation by the Tax Administrator of rules and regulations authorized by this Section shall not constitute a new or increased tax requiring approval by the voters of the City.

41.15 The Tax Administrator shall annually verify that the taxes owed under this chapter have been properly applied, exempted, collected and remitted.

3.38.050 - COLLECTION OF TAX AND REGISTRATION OF DISTRIBUTORS Every Person engaged in or about to engage in business as a Distributor in the City shall immediately register with the City in the manner and form determined by the Tax Administrator. Persons engaged in such business must be registered no later than thirty (30) days after the date the tax imposed by this chapter becomes effective on May 1, 2025, but such privilege of such registration after the date of imposition of such tax shall not relieve any Person from the obligation or payment or collection of tax on and after the date of imposition thereof, regardless of registration.

In order to aid in the collection of taxes due to the City under this chapter, any Distributor or Retailer that distributes, receives or sells Sugar-Sweetened Beverage Product(s) shall provide information to the City regarding the Distribution of these products in accordance with rules and regulations adopted by the Tax Administrator.

The City Council is authorized to have the taxes imposed by this chapter collected by the County of Santa Cruz or the California Board of Equalization in conjunction with the collection of other taxes for the City. If the City Council exercises this authorization, the duties and responsibilities of the Tax Administrator shall be given, as appropriate, to the County of Santa Cruz or the California Board of Equalization, which may delegate such duties and responsibilities as necessary and as authorized by law.

3.38.055 - PENALTIES AND INTEREST
Any Distributor who fails to file a tax return and pay any amount of tax required to be collected and paid to the City within the time required by the rules and regulations established by the Tax Administrator shall pay a penalty of ten (10) percent of the tax, in addition to the tax, plus interest, computed on the amount of delinquent tax, inclusive of penalties, at the rate of one and one-half (1.5) percent per month, or fraction thereof, from the date on which the tax or the amount of tax required to be collected became due and payable to the City and until the date of payment.

If the Tax Administrator determines that any tax found to be due under this chapter or the delinquent filing of a tax return is due to fraud, intentional disregard or an intent to evade this part or authorized rules and regulations, a penalty of fifteen (15) percent shall be added thereto in addition to any other penalties which may be imposed.

3.38.060 - TAX DEEMED DEBT TO CITY
The amount of any tax, penalties and interest imposed by the provisions of this chapter shall be deemed a debt to the city and any Person carrying on any business taxable under this chapter without first having paid such tax shall be liable in an action in the name of the City in any

41.16 court of competent jurisdiction for the amount of the tax, and penalties and interest imposed on such Person and for any and all cost recovery, including attorneys’ fees in the enforcement of this chapter.

3.38.070 - CREDITS AND REFUNDS
Any tax under this chapter that has been paid more than once or has been erroneously or illegally collected or received by the City shall be refunded as determined by the Tax Administrator.

Any tax under this chapter that has been returned to the Distributor within six (6) months of the initial Distribution and for which the entire purchase price has been refunded in cash or credit shall be refunded as determined by the Tax Administrator.

Claims must be filed with the Tax Administrator and determined in accordance with the rules and regulations to be established by the Tax Administrator, within one year from the date of payment of the tax to the City. No refund shall be paid under this section unless claimant establishes entitlement thereto by written documentation.

3.38.080 - EXAMINATION OF BOOKS, RECORDS, WITNESSES -

CONFIDENTIALITY OF INFORMATION - PENALTY
It shall be the duty of a Distributor liable for the payment to the City of the tax imposed by this chapter to keep and preserve, for a period of four years, all records, complete and accurate, as may be necessary to determine the amount of such tax, interest, penalties and enforcement charges as the Distributor may be liable for payment to the City.

The Tax Administrator shall have the power to audit and examine all books and records of every Person liable for the payment to the City of the tax imposed by this chapter, including both state and federal income tax returns, California sales tax returns, or other evidence documenting the gross receipts of Persons engaged in Distribution in the City for the purpose of ascertaining the amount of tax, if any, required to be paid by the provisions hereof, and for the purpose of verifying any statements or any item thereof when filed by any Person pursuant to the provisions of this chapter. If such Person, after written demand by the Tax administrator, refuses to make available for audit, examination or verification such books, records or other evidence as the Tax Administrator requests, the Tax Administrator may, after full consideration of all information within his or her knowledge concerning the business and activities of the Person, make an assessment in the manner provided in this chapter of any taxes estimated to be due.

Every Person subject to the provisions of this chapter is directed and required to furnish to the Tax Administrator or duly authorized agent or employee, the means, facilities and opportunity for making such examination and investigations. The Tax Administrator is authorized to examine a Person under oath, for the purpose of verifying the accuracy of any declaration made, or if no declaration was made, to ascertain the tax or, if applicable, registration fees, due under this chapter. In order to ascertain the tax due under this chapter, the Tax Administrator

41.17 may compel, by administrative subpoena, the production of relevant books, papers and records and the attendance of all Persons as parties or witnesses.

Except for disclosures to agents, attorneys, or employees of the City necessary to the purpose of administering or enforcing the tax, or in compliance with a court order, or in connection with an appeal, hearing or court action, City employees shall maintain the confidentiality of all business and personal information and documents furnished to or obtained by the Tax Administrator in connection with the collection or administrative proceedings relating to the determination and assessment of taxes.

The refusal to submit to such examination or production by any employer or Person subject to the provisions of this chapter shall be deemed a violation of this chapter, and administrative subpoenas shall be enforced pursuant to applicable state law.

3.38.085 - FAILURE TO COLLECT AND REPORT TAX – DETERMINATION OF

TAX BY DIRECTOR OF FINANCE
If any Person shall fail or refuse to provide records for audit, or to collect the tax and to make, within the time provided any report and remittance of said tax or any portion thereof required by this chapter, the Tax Administrator shall have the discretion to make an estimate of the tax due based on the facts and information available.

As soon as Tax Administrator shall procure such facts and information upon which to base the assessment of any tax imposed by this chapter and payable by the Distributor who has failed or refused to provide any requested records, the Tax Administrator shall proceed to determine and assess against such Distributor the tax, interest and penalties provided for by this chapter.

In case such determination is made, the Tax Administrator shall give a notice of the amount so assessed by serving it personally or by depositing it in the United States mail, postage prepaid, addressed to the Distributor so assessed at the last known place of address.

Such Distributor may within ten (10) days after the serving or mailing of such notice make application in writing to the Tax Administrator for a hearing on the amount assessed. If application by the Person for a hearing is not made within the time prescribed, the tax, interest and penalties, if any, determined by the Tax Administrator shall become final and conclusive and immediately due and payable. If such application is made, the Tax Administrator shall give not less than five (5) days’ written notice in the manner prescribed herein to the Person to show cause at a time and place fixed in the notice why the amount specified therein should not be fixed for such tax, interest and penalties. At such hearing the Distributor may appear and offer evidence why such specified tax, interest and penalties should not be so fixed.

After such hearing the Tax Administrator shall determine the proper tax to be remitted and shall thereafter give written notice to the Distributor in the manner prescribed herein of such determination and the amount of such tax, interest and penalties. The amount determined to be due shall be payable after fifteen days unless an appeal is taken as provided in Section

3.38.090.

41.18 3.38.090 - APPEAL
Any Distributor aggrieved by any decision of the Tax Administrator with respect to the amount of such tax, interest and penalties, if any, owed under this chapter, may appeal to the city council in accordance with the provisions of Chapter 1.16 of the Santa Cruz Municipal Code.

3.38.100 - PENALTY FOR VIOLATIONS
Any Distributor violating any of the provisions of this chapter shall be guilty of a misdemeanor and shall be punishable by a fine of not more than one thousand dollars or by imprisonment in the county jail for a period of not more than six months or by both fine and imprisonment, as provided in Title 4 of this code, in addition to the penalties provided for in this chapter or elsewhere in this code.

Any Distributor who fails or refuses to register as required in this chapter, or to furnish any return required to be made or who fails or refuses to furnish a supplemental return or other data required by the Tax Administrator, or who renders a false or fraudulent return or claim, is guilty of a misdemeanor, and is punishable as stated above, in addition to being subject to the other penalties provided for in this chapter or code, or elsewhere. Any Person required to make, render, sign or verify any report or claim who makes any false or fraudulent report or claim with intent to defeat or evade the determination of any amount due required by this chapter to be made is guilty of a misdemeanor and is punishable as stated above, in addition to the penalties provided for in this chapter or code, or elsewhere.

All remedies prescribed by this chapter or code, or any other provisions of law, and the use of one or more remedies by the City are cumulative, and shall not bar the use of any other remedy for the purpose of enforcing the provisions of this chapter.

3.38.110 - COLLECTION DATE
Distributors shall start collecting the tax on May 1, 2025.

3.38.120 - UNRESTRICTED GENERAL REVENUE PURPOSES
All tax revenue collected and remitted to the City pursuant to this chapter shall be deposited in the City of Santa Cruz unrestricted general fund and can be spent for unrestricted general revenue purposes.

3.38.130 - NOT A SALES AND USE TAX
The tax imposed by this measure is a general excise tax on conducting business within the City of Santa Cruz. It is not a sales tax or use tax or other excise tax on the sale, consumption, or use of Sugar-Sweetened Beverage Product(s).

41.19 3.38.140 – SEVERABILITY
Should any provision of this chapter, or its application to any person or circumstance, be determined by a court of competent jurisdiction to be unlawful, unenforceable or otherwise void, that determination shall have no effect on any other provision of this chapter or the application of this chapter to any other person or circumstance and, to that end, the provisions hereof are severable.

3.38.150 AMENDMENT
This ordinance may only be amended by a vote of the people, if the amendment would result in the tax being imposed, extended, or increased in a manner not authorized by this ordinance as originally approved by the voters. The City Council of the City of Santa Cruz is hereby authorized to amend Chapter 3.38 of the Santa Cruz Municipal Code as adopted by this ordinance in any manner that does not increase the tax rates, or otherwise constitute a tax increase for which voter approval is required by Article XIII C of the California Constitution.” Section 2. EFFECTIVE DATE. This ordinance relates to the levying and collecting of a general excise tax, and shall take effect immediately if the ordinance is approved by a simple majority of voters voting on the question at the November 5, 2024 election. If approved by the voters, collection of the tax shall commence as specified in Section 3.38.110.

PASSED AND ADOPTED by a majority vote of the electorate of the City of Santa Cruz on November 5, 2024. Pursuant to Section 2, above, the ordinance became effective immediately upon such adoption.

Attest: _________________________________
Bonnie Bush, City Clerk Administrator

41.20 Excerpts from
Source Information
Regarding SSB Tax

41.21 Original Investigation
Evaluation of Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes Across the US
Scott Kaplan, PhD; Justin S. White, PhD; Kristine A. Madsen, MD; Sanjay Basu, MD, PhD; Sofia B. Villas-Boas, PhD; Dean Schillinger, MD Abstract
IMPORTANCE Sugar-sweetened beverage (SSB) taxes are promoted as key policies to reduce cardiometabolic diseases and other conditions, but comprehensive analyses of SSB taxes in the US have been difficult because of the absence of sufficiently large data samples and methods limitations.

OBJECTIVE To estimate changes in SSB prices and purchases following SSB taxes in 5 large US cities.

DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study with an augmented synthetic control analysis, changes in prices and purchases of SSBs were estimated following SSB tax implementation in Boulder, Colorado; Philadelphia, Pennsylvania; Oakland, California; Seattle, Washington; and San Francisco, California. Changes in SSB prices (in US dollars) and purchases (volume in ounces) in these cities in the 2 years following tax implementation were estimated and compared with control groups constructed from other cities. Changes in adjacent, untaxed areas were assessed to detect any increase in cross-border purchases. Data used for this analysis spanned from January 1, 2012, to February 29, 2020, and were analyzed between June 1, 2022, and September 29, 2023.

MAIN OUTCOMES AND MEASURES The main outcomes were the changes in SSB prices and volume purchased.

RESULTS Using nutritional information, 5500 unique universal product codes were classified as SSBs, according to tax designations. The sample included 26 338 stores—496 located in treated localities, 1340 in bordering localities, and 24 502 in the donor pool. Prices of SSBs increased by an average of 33.1% (95% CI, 14.0% to 52.2%; P < .001) during the 2 years following tax implementation, corresponding to an average price increase of 1.3¢ per oz and a 92% tax passthrough rate from distributors to consumers. SSB purchases declined in total volume by an average of 33.0% (95% CI, −2.2% to −63.8%; P = .04) following tax implementation, corresponding to a −1.00 price elasticity of demand. The observed price increase and corresponding volume decrease immediately followed tax implementation, and both outcomes were sustained in the months thereafter. No evidence of increased cross-border purchases following tax implementation was found.

CONCLUSIONS AND RELEVANCE In this cross-sectional study, SSB taxes led to substantial, consistent declines in SSB purchases across 5 taxed cities following price increases associated with those taxes. Scaling SSB taxes nationally could yield substantial public health benefits.

JAMA Health Forum. 2024;5(1):e234737.

Corrected on February 16, 2024. doi:10.1001/jamahealthforum.2023.4737 Key Points
Question What changes occurred in
sugar-sweetened beverage (SSB) prices
and purchase volume after SSB taxes
were implemented in 5 large US cities?
Findings In this cross-sectional study,
SSB taxes in Boulder, Colorado;
Philadelphia, Pennsylvania; Oakland,
California; San Francisco, California; and
Seattle, Washington, were associated
with a 33.1% composite increase
in SSB prices (92% pass-through of
taxes to consumers) and a 33%
reduction in purchase volume, without
increasing cross-border purchases.

The results were sustained in the
months following tax implementation.

Meaning The results suggest
substantial, consistent declines in SSB
purchases across several US cities;
insofar as reducing SSB consumption
can improve population health, scaling
SSB taxes more broadly should be
considered.
+ Supplemental content
Author affiliations and article information are
listed at the end of this article.

Open Access. This is an open access article distributed under the terms of the CC-BY License.

JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 1/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.22 Introduction
Sugar-sweetened beverages (SSBs) are a major source of nonnutritional calories and are associated with serious adverse health outcomes, including type 2 diabetes, obesity, cardiovascular disease, gum disease, caries, and others that contribute to morbidity and mortality.1,2 Because of the associations between SSBs and these outcomes, excise taxes on SSBs have been proposed in the US and around the world. As of November 2022, 8 US jurisdictions and more than 50 countries have implemented some form of SSB tax.3 Several systematic reviews and meta-analyses have examined the association of SSB excise taxes with both prices and consumption.4-6 The most recent international review finds a pass-through rate from distributors to consumers of 82% (95% CI, 66%-98%), a mean reduction in SSB sales of 15% (95% CI, −20% to −9%), and an average demand elasticity of −1.59 (95% CI, −2.11 to −1.08).7
Yet, nearly all US-based studies of SSB taxes analyzed 1 taxed city and compared it with a control city. To our knowledge, only 2 existing studies have evaluated joint estimates of SSB taxes across multiple taxed cities.8,9 However, recent statistical advances suggest that these estimates likely suffer from bias associated with conventional 2-way fixed effects (TWFE) approaches that cannot account for time-varying confounders, which differ between experimental and control populations.10 Unbiased estimation of a composite effect, which provides a pooled estimate of SSB taxes across multiple taxed cities, is critical for understanding the generalizability of SSB tax outcomes to different localities with heterogeneous characteristics; such an estimate is complementary to existing estimates from individual localities with SSB taxes in place. This estimate, though imperfect, also better informs the potential effectiveness of a nationwide tax, which was recommended by a recent federal commission on diabetes11 and is especially relevant considering the beverage industry’s recent efforts to preempt localities from levying SSB taxes.12 In this cross-sectional study with an augmented synthetic control (ASC) analysis, retail sales data from Boulder, Colorado; Philadelphia, Pennsylvania; Oakland, California; Seattle, Washington; and San Francisco, California, were used to estimate the composite effect of SSB taxes on SSB prices and volume purchased. We applied recent advances in statistical methods to estimate an ASC model with staggered adoption, which produces joint estimates from taxes in several treated cities, despite different timing of policy implementation. Unlike conventional TWFE approaches, an ASC model with staggered adoption addresses time-invariant and time-varying unobserved confounders that differ between taxed cities and their untaxed comparators.10,13,14 We also estimated composite changes in cross-border shopping in untaxed adjacent areas to examine if consumers offset SSB purchases in bordering localities following SSB tax implementation.

Methods
This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.15 Informed consent was waived because the data were deidentified. The research was determined not to meet the criteria for human participant research by the institutional review board at the University of California, San Francisco.

The data used in this analysis spanned from January 1, 2012, to February 29, 2020, and were analyzed between June 1, 2022, and September 29, 2023.

Retail scanner data on SSB prices (in US dollars) and volume sold (in ounces) and a staggered adoption ASC approach were used to estimate the composite change in prices and purchases following the implementation of SSB taxes in Boulder, Philadelphia, Oakland, Seattle, and San Francisco. We also estimated composite changes in cross-border shopping using adjacent, untaxed areas.

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 2/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.23 Data Collection
The primary data set was the Nielsen Corporation’s retail scanner data. It consisted of product-weekstore observations from selected chain stores in nearly all 3-digit zip codes across the US (871) over the study period from January 1, 2012, to February 29, 2020. The data included total units sold and the average sale price per unit for each observation. Beverage products from this data set were supplemented with nutritional and general product information from Label Insight (Nielsen Consumer LLC)16 and hand-coded nutritional information. This enabled the classification of individual beverage products as SSBs or not, on the basis of tax regulations across the 5 cities.

Artificially sweetened beverages were not included in the analysis, despite coverage in Philadelphia’s SSB tax. The eMethods in Supplement 1 contain additional details on product selection and tax status classification procedures.

The Table provides a summary of information about the study’s localities. There were 5 taxed 3-digit zip codes examined: 803 (Boulder), 191 (Philadelphia), 946 (Oakland), 981 (Seattle), and 941 (San Francisco). Each of these 3-digit zip codes formed the full set of taxed jurisdictions. The California cities Berkeley and Albany (947) were not included because they were taxed at different times and could not be separately identified from one another (see Limitations). Localities with sales taxes, which include the District of Columbia and Navajo Nation, were omitted because they tend to be smaller in magnitude and less likely to change purchasing behavior. Among the 5 treated localities in this cross-sectional study, the 3 dates in which SSB taxes were implemented varied by city—in Philadelphia, the SSB tax was implemented January 1, 2017; in Boulder and Oakland, July 1, 2017; and in San Francisco and Seattle, January 1, 2018. Tax amounts ranged from 1¢ per oz to 2¢ per oz. Crossborder purchasing was examined in all immediately adjacent 3-digit zip codes, of which there were 13 (Table). These areas did not contain any taxed jurisdictions.

Outcome Variables
Two primary outcome measures were examined, including the monthly change in total number of ounces of SSB products sold in treated localities compared with the synthetic control localities following tax implementation. Total ounces of SSB products sold was the outcome used in the crossborder shopping analysis.

Statistical Analysis
This cross-sectional study used an ASC approach.17 The original synthetic control method uses a datadriven approach to construct a synthetic control unit as a weighted average of all potential control units that best match the treated unit on both the pretreatment outcome and prognostic factors.18 The ASC approach extends this method by (1) allowing for multiple treated units experiencing treatment at different times and (2) providing a robust correction procedure when the synthetic Table. Descriptive Statistics of 3-Digit Zip Codes in Primary Analysis Variable
Three-digit zip code
941 (SF) 946 (Oak) 191 (Phil) 803 (Boul) 981 (Sea)
Bordering
localitiesa Donor poolb
Three-digit zip codes, No. 1 1 1 1 1 13 279
Stores, No. 103 41 213 26 113 1340 24 502
Date tax implemented January 1, 2018 July 1, 2017 January 1, 2017 July 1, 2017 January 1, 2018 NA NA Pretax months in data, No. 72 66 60 66 72 NA NA
Posttax months in data, No. 24 30 36 30 24 NA NA
Dollars per oz 0.01 0.01 0.015 0.02 0.0175 NA NA
Abbreviations: Boul, Boulder, Colorado; NA, not applicable; Oak, Oakland, California; Phil, Philadelphia, Pennsylvania; Sea, Seattle, Washington; SF, San Francisco, California. a Bordering 3-digit zip codes comprise all immediately adjacent 3-digit zip codes to each of the 5 treated zip codes, including 800, 804, 805, 945, 948, 080, 081, 940, 949, 980, 982, 983, and 984.
b Donor zip codes consist of all 3-digit zip codes with a % urban value within 1 SD (0.35) of the mean urbanicity of the 5 treated localities (0.98).

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 3/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.24 unit’s pretreatment outcomes do not closely match those of the treated units. Using a donor pool of untaxed, nonbordering 3-digit zip codes, a synthetic treated unit was constructed for each of the 5 treated cities using pretax SSB prices and purchases, as well as a set of time-invariant characteristics from the 2010 Decennial Census and 2016 American Community Survey.19,20 Data were analyzed using R statistical software, version 4.3.2 (R Project for Statistical Computing).

Price Pass-Through and Volume Sold
The primary ASC analyses were estimated at the 3-digit zip code–by-month level. We used the weighted average shelf price of SSBs and aggregated the total ounces purchased of SSBs at this unit of observation. Then, separate estimations assessed the composite posttax implementation change in shelf prices and volume sold in treated localities compared with a synthetic locality for each. Each individual city was given equal weight in calculating the composite outcome. The percentage change in shelf prices and volume sold was computed using pretax average shelf prices and volume sold in the treated localities.

Adhering to the approach in the study by Abadie,21 the donor pool was limited to units with similar characteristics, namely jurisdictions within 1 SD (0.35) of the mean urbanicity level of the 5 treated localities (0.98), following the US Census definition of urban vs rural. A total of 284 threedigit zip codes remained, including the 5 treated localities, but omitting the 13 border localities.

Sociodemographic and geographic characteristics used in constructing the synthetic units are shown in Figure 1 and described in the second section of the eMethods in Supplement 1. These characteristics were chosen on the basis of previous research examining SSB taxes.22-25 To determine the statistical significance of the ASC average treatment effects, which are calculated as the average posttax percentage changes in SSB prices and purchases for treated units relative to that of the synthetic control units, placebo estimates were generated for each donor unit one by one, as if each of those units had been treated.18 Because treated localities implemented taxes at different times, this procedure was repeated for each treated locality, generating 279 × 5 = 1395 placebo estimates. To generate P values, the ratio of mean squared prediction error in the posttax vs pretax period was computed for the composite unit estimate and each placebo estimate, which were then ranked from largest to smallest.26 The P value was calculated as the ratio of the composite unit ranking to the total number of units (1396) and indicated statistical significance when P < .05. More details are provided in the eMethods in Supplement 1.

Cross-Border Purchasing
To fully quantify the changes following SSB taxes in treated cities, we also explored whether purchasing behavior changed in adjacent 3-digit border zip codes. The same ASC procedure was implemented, except all adjacent border localities were considered treated, and taxed cities were excluded. Because border localities tended to be semiurban or suburban, the subsample of donor pool units was modified to those featuring an urbanicity level within 1 SD (0.35) of the mean urbanicity of the 13 border localities (0.75). A total of 369 three-digit zip codes remained, including the 13 border localities. This analysis used the same Census characteristics and P value calculation approach.

Sensitivity Analysis
To assess sensitivity, 2 different urbanicity cutoffs were used to determine the donor pool subsample. Both an urbanicity level of 0.9 and 0.85 were used, reducing the donor pool of 3-digit zip codes to 204 and 226, respectively.

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 4/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.25 Results
Sample Composition
The main analytic sample included 28 512 three-digit zip code–by-month observations from 297 three-digit zip codes across 98 months. Using nutritional information from the supplementary handcoded and Label Insight data, 5500 unique universal product codes (UPCs) were confirmed as SSBs according to the tax designations. The sample included 26 338 stores—496 located in treated localities, 1340 in bordering localities, and 24 502 in the donor pool. The Table provides summary information for each group of localities.

Figure 1 compares each treated unit with its corresponding synthetic unit, focusing on pretax mean SSB volume in ounces and the 12 sociodemographic and geographic covariates. (In Supplement 1, eFigure 1 displays the price analysis comparisons.) Variables were scaled to be between 0 and 100, so that the units of measure were comparable. In most instances, these values were highly similar (within 5 index points), and no comparisons differed by more than 14 index points. In Supplement 1, eFigure 2 displays sample distributions of each Census characteristic.

Figure 1. Treated vs Synthetic Values of Pretreatment Sugar-Sweetened Beverage (SSB) Sales Volume and Sociodemographic Characteristics 0 40 60 80 100
Scaled mean
20 Variable
Pretax mean SSB volume, oz
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Population
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Median age, y
Philadelphia
Seattle
Oakland
San Francisco
Boulder
No. housing units
Philadelphia
Seattle
Oakland
San Francisco
Boulder
White, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Black, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
American Indian/Alaska Native, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
0 40 60 80 100
Scaled mean
20 Variable
Asian, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Native Hawaiian, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Other race, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Hispanic, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Poverty, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Aged 18-64 y, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
Urban, %
Philadelphia
Seattle
Oakland
San Francisco
Boulder
This plot shows the scaled mean values of pretax outcomes and prognostic covariates included in the synthetic control analysis of SSB volume purchased. Mean values are scaled to be between 0 and 100 on the basis of each variable’s maximum and minimum values found in the primary sample. Shaded dots correspond to the mean value for a treated city, and hollow dots correspond to its synthetic control. Other race and ethnicity, as determined by the 2010 US Census, included multiracial and Hispanic individuals.

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 5/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.26 ASC Analyses of SSB Prices and Volume Sold
In the composite treated locality, shelf prices of SSB products increased by an average of 33.1% (95% CI, 14.0%-52.2%; P < .001) in the 2 years following tax implementation, relative to the average percentage change in the composite synthetic locality. This corresponded to an average price increase of 1.3¢ per oz (Figure 2) and a 92% price pass-through rate (eFigure 3 in Supplement 1). The volume of SSBs purchased declined by an average of 33.0% (95% CI, −2.2% to −63.8%; P = .04) during the same time frame, relative to the average percentage change in the composite synthetic locality. This corresponded to an average monthly change of 18 534 oz/store-month (Figure 2).

Together, these estimates yielded a −1.00 price elasticity of demand, suggesting SSB purchasing behavior was responsive to changes in shelf prices (Figure 2). Figure 2 also shows changes in shelf prices and volume purchased for the 5 taxed localities individually. The demand elasticity estimates were relatively consistent across taxed localities, ranging from −0.80 (Philadelphia) to −1.37 (Seattle).

Shelf price changes for individual cities were significant at the 10% level, yet null changes in volume purchased could not be rejected for each city at the 10% level.

Figure 3A shows time-varying ASC results for SSB shelf prices, and Figure 3B shows this information for volume sales. The blue line indicates the difference between the composite treated unit and synthetic unit, and the gray lines represent each placebo estimate. In both analyses, a close fit between the composite treated unit and synthetic unit was found in the pretax period. There was Figure 2. Composite and Individual Locality Demand Elasticity Estimates –60 –20 0 20 40 60
Change, %
–40
Volume change,
Locality % (95% CI) P value
Price change,
% (95% CI)
Composite 33.1 (14.0 to 52.2) –33.0 (–63.8 to –2.2) .04 Philadelphia 58.3 (7.4 to 109.3) –46.8 (–119.4 to 25.8) .21 Boulder 45.1 (9.1 to 81.2) –41.5 (–104.8 to 21.9) .20
San Francisco 33.4 (3.5 to 63.3) –36.4 (–94.5 to 21.7) .22 Oakland 24.4 (0.8 to 48.1) –31.0 (–85.0 to 23.0) .26
–19.2 (–47.3 to 9.0) .18
P value
.001
.03
.01
.03
.04
.07
Price
elasticity
–1.00
–0.80
–0.92
–1.09
–1.27
Seattle 13.9 (–1.2 to 29.1) –1.37
Volume change Price change
This plot shows the percentage change in volume sold measured in ounces (orange squares) and the percentage change in shelf prices measured in US dollars (blue circles) for the augmented synthetic control with staggered adoption composite analysis.

The plot shows the same information for the augmented synthetic control analyses of the 5 treated localities individually. Price elasticities of demand are provided, and 95% CIs and P values for each percentage change in price or volume are also provided.

Figure 3. Augmented Synthetic Control Estimates for Composite Changes in Sugar-Sweetened Beverage (SSB) Price and Sales Volume 100
50 0
–50
–100
Scaled treatment effect, %
Event-time, mo
A Changes in SSB prices
Start of tax
–60 –48 –36 –24 –12 0 12 24
Effect estimate,

33.1% (95% CI, 14.0% to 52.2%);
P=.001
100
50 0
–50
–100
Scaled treatment effect, %
Event-time, mo
B Changes in SSB volume sales
Start of tax
–60 –48 –36 –24 –12 0 12 24
Effect estimate,
–33.0% (95% CI, –2.2% to –63.8%);
P=.04
A, This panel shows the percentage change in shelf prices (in US dollars) in response to implementing an excise SSB tax for the staggered adoption composite analysis. B, This panel shows the percentage change in volume sold (in oz). The blue line represents the composite treated unit, and the gray lines represent in-space placebo estimates from the donor pool, which comprise untaxed localities. Percentage changes are calculated for the average of the pretreatment means of each of the 5 treated localities. The light blue dotted line represents the start of the SSB tax. The composite effect size estimates and P values are provided in each panel.

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 6/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.27 a steep, immediate increase in shelf prices and decrease in volume sales following tax implementation, which was sustained in the months thereafter.

Each city in the composite analysis was equally weighted. The procedure and context through which each city introduced an SSB tax varies, and the findings are intended for policymakers considering tax implementation in specific geographies. The population-weighted composite estimates are similar (eFigures 8 and 9 in Supplement 1).

The analyses for different urbanicity cutoffs generated similar results (eFigures 10 and 13 in Supplement 1). In Supplement 1, eFigures 5 and 6 show the individual city ASC analyses.

ASC Analyses of Cross-Border Shopping
Figure 4 shows the time-varying ASC results for cross-border SSB volume sales. There was no statistically significant mean change in cross-border purchases of SSBs following tax implementation (−2.4%; 95% CI, −12.8% to 8.1%; P = .67), which remained stable in the years following the tax. No significant change in cross-border SSB volume purchases was observed in each taxed city (eFigure 4 in Supplement 1). Estimates for different urbanicity cutoffs provided similar findings (eFigures 12 and 15 in Supplement 1). In Supplement 1, eFigure 7 displays the time-varying cross-border analyses for each taxed city.

Discussion
In this cross-sectional study with an ASC analysis, SSB excise taxes were associated with large, consistent declines in SSB purchases across 5 US taxed cities following tax-driven price changes.

Quasi-experimental methods were used to estimate the overall changes following SSB taxes implemented at different times and locations relative to a synthetic control of untaxed areas. The results show shelf prices of SSB products increased by an average of 33.1% (1.3¢ per oz) in the years following SSB tax implementation, corresponding to a 92% price pass-through rate from distributors to consumers. Volume sales fell by 33.0% during the same time frame, without evidence of changes in cross-border shopping in untaxed adjacent areas.

Although the estimates generally support previous estimates from single-city studies, these results help answer the critical question of how much variation across taxed localities is due to the unique characteristics of a locality vs the generalizable outcomes of a tax. Compared with a recent international meta-analysis of SSB taxes, the results suggest a slightly higher pass-through rate, a substantially larger reduction in volume purchased, and moderately less demand responsiveness to price changes.6 These modest discrepancies may reflect differences in geographic areas of comparators, store sample composition, and greater accounting of unmeasured confounders in this Figure 4. Augmented Synthetic Control Estimates of Composite Changes in Sugar-Sweetened Beverage (SSB) Sales Volume in Border Areas

1.0 0.5
0 –0.5
–1.0
Scaled treatment effect, %
Event-time, mo
Start of tax
–60 –48 –36 –24 –12 0 12 24
Effect estimate,
–2.4% (95% CI, –12.8% to 8.1%);
P=.67
This figure shows the percentage change in volume
sold (in oz) from the staggered adoption composite
analysis in immediately adjacent bordering 3-digit zip
codes. These data were examined in response to
implementing an excise SSB tax in the 5 treated zip
codes. The dark blue line represents the composite
adjacent border unit, and the gray lines represent
in-space placebo estimates from the donor pool.

Percentage changes are calculated for the average
of the pretreatment means of each of the 12 adjacent
border localities. The light blue dotted line represents the start of the SSB tax. The composite effect size
estimates and P values are provided.

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 7/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.28 analysis than in previous studies. Additionally, conflicting findings have been found regarding crossborder purchasing following SSB taxes, with some studies pointing to significant increases and others finding no changes.27-30 The results provided no evidence of changes in cross-border purchasing.

To further contextualize the findings, we estimated a TWFE event-study model, detailed in the third section of the eMethods in Supplement 1. This model has been the primary approach taken in previous SSB tax evaluation studies. In Supplement 1, eTable 3 shows the point estimates are generally comparable with the ASC estimates, although some moderate differences exist. Inspection of the prepolicy coefficients in the event-study plots suggests that these estimates have varying degrees of bias associated with imperfect pretrends (eFigures 16-19 in Supplement 1).31,32 The TWFE estimates are much more precisely estimated than the ASC estimates, in part because the TWFE CIs may be overly narrow.33-35 Nevertheless, this trade-off highlights this study’s focus on generating unbiased estimates at the partial expense of precision.

It is important to interpret these estimates in the context of projected health benefits. Several studies have found that a 15% to 20% increase in price/decrease in consumption generates significant health benefits, including reductions in myocardial infarction events, ischemic heart disease, coronary heart events, strokes, diabetes, and obesity.36-38 This study estimated a 33.1% increase in price and a corresponding 33.0% decrease in volume, suggesting health benefits at least as substantial as those found previously.

Additionally, studies have suggested that SSB taxes are highly cost-effective.22,37,39 Wang et al37 found a nationwide tax could have avoided $17 billion in medical costs between 2010 and 2020. Lee et al39 found approximately $53 billion in cost savings throughout an average individual lifetime.

More recently, White et al22 found that a 27% reduction in consumption in Oakland is expected to accrue more than $100 000 per 10 000 residents in societal cost savings during a 10-year period.

This study’s findings suggest SSB taxation would likely generate significant improvements in population health and substantial cost savings.

Limitations
First, the retail scanner data identify purchasing behavior and not direct consumption. It is possible, though unlikely, that taxed populations consumed a different share of purchased SSBs than did untaxed control populations (eg, producing more waste). Second, the data were geocoded by 3-digit zip code. This prevented Berkeley and Albany (3-digit zip code 947) from being included because they could not be separately identified and were taxed at different times. The 3-digit zip codes for included taxed cities contained a small number of untaxed jurisdictions, accounting for less than 7% of the total population of these areas (eTable 2 in Supplement 1). However, this misclassification should only lead to an underestimate of the changes following tax implementation.

We also lacked nutritional information for certain beverage UPCs. Of the UPCs of SSBs in the scanner data, we successfully matched 84.0% of sales volume in ounces using Label Insight and hand-coded data featuring nutritional information. To the extent that the set of unmatched UPCs was similar across taxed and untaxed jurisdictions, the findings should be unaffected. Additionally, the scanner data contained only a subsample of all stores in each zip code; thus, the data did not include all volume sales. Using SSB tax revenues to estimate total volume sales in treated localities, coverage from this set of products was 12.7% (eTable 1 in Supplement 1). The coverage estimates were similar but slightly lower than recent SSB tax evaluations using Nielsen data.29,40 Lower coverage in Philadelphia was partially due to the exclusion of artificially sweetened beverages from this analysis. Coverage could not be calculated in donor zip codes because there were no SSB taxes in place. However, the ASC estimation generated a reliable counterfactual group from the existing sample of donor zip codes, which should mitigate any unintended bias caused by unequal SSB coverage across treatment and control localities.

Next, although the ASC estimates for each individual city in the volume analysis (Figure 2; eFigure 6 in Supplement 1) were similar to those in prior studies,7 they were relatively imprecise, and a null effect could not be rejected at the 5% level. Furthermore, although the composite estimates JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 8/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.29 for the volume analysis were much more precise, reductions in purchases as small as 2% or as large as 64% could not be ruled out at a 95% CI level. While synthetic control methods deliver less biased estimates than difference-in-differences approaches, they also generate less statistical power.41 However, difference-in-differences studies involving a small number of treated units may underestimate the true variance of effect estimates.33-35 As more localities introduce SSB taxes, synthetic control methods with staggered adoption will have greater precision.

In addition, only posted shelf prices were observed in the scanner data, which may lead to underestimates of pass-through rates. While excise taxes are generally reflected in shelf prices, certain retailers may have only included the tax once products were scanned at the register.42 Moreover, the scanner data were primarily composed of information from large chain stores. Thus, these results may not extend to independent stores, although similar estimates have been found in those settings.43 Finally, the 5 treated localities studied here, while geographically distinct and racially, ethnically, and socioeconomically diverse, were not fully representative of the US population.

Therefore, the findings may not be fully generalizable on a national scale, a limitation most relevant to less urban populations.

Conclusions
In this cross-sectional study with an ASC analysis, SSB taxes in Boulder, Philadelphia, Oakland, San Francisco, and Seattle were associated with 33.1% composite increases in SSB prices (92% passthrough rate) and 33.0% reductions in SSB purchases, with no offset through cross-border purchases of SSBs. The changes in prices and purchases remained stable in the years following tax implementation. The findings have important implications for the potential efficacy of SSB taxes across larger geographic jurisdictions and at the national level. Scaling SSB excise taxes across the US would likely generate significant population health benefits and medical cost savings.

ARTICLE INFORMATION
Accepted for Publication: October 26, 2023.

Published: January 5, 2024. doi:10.1001/jamahealthforum.2023.4737 Correction: This article was corrected on February 16, 2024, to fix the upper 95% CI value in Figure 3A from 52.5% to 52.2%.

Corresponding Author: Scott Kaplan, PhD, Department of Economics, US Naval Academy, 106 and 107 Maryland Ave, Annapolis, MD 21402 ([email protected]).

Author Affiliations: Department of Economics, US Naval Academy, Annapolis, Maryland (Kaplan); Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts (White); School of Public Health, University of California, Berkeley (Madsen); Institute of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada (Basu); Department of Agricultural & Resource Economics, University of California, Berkeley (Villas-Boas); Division of General Internal Medicine, Center for Vulnerable Populations, San Francisco General Hospital/University of California, San Francisco (Schillinger).

Author Contributions: Prof Kaplan had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Basu and Villas-Boas contributed equally to this work.

Concept and design: All authors.

Acquisition, analysis, or interpretation of data: Kaplan, White, Madsen, Schillinger.

Drafting of the manuscript: Kaplan, White, Schillinger.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Kaplan, White.

Obtained funding: Schillinger.

JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 9/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.30 Administrative, technical, or material support: Kaplan, Madsen, Schillinger.

Supervision: Kaplan, White, Basu, Villas-Boas, Schillinger.

Conflict of Interest Disclosures: Dr Basu reported grants from the National Institutes of Health; Centers for Disease Control and Prevention; personal fees from the University of California, San Francisco; Collective Health; Waymark; and HealthRIGHT 360 outside the submitted work. No other disclosures were reported.

Funding/Support: This work was supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases (R01 DK116852 and 2P30 DK092924), and the Centers for Disease Control and Prevention’s National Center for Chronic Disease Prevention and Health Promotion (U18DP006526).

Role of the Funder: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: All estimates and analyses in this article are by the authors and not by the Nielsen Corporation.

Researchers’ analyses were calculated (or derived) based in part on data from Nielsen Consumer LLC and marketing databases provided through the NielsenIQ data sets at the Kilts Marketing Data Center at the University of Chicago Booth School of Business. The conclusions drawn from the NielsenIQ data are those of the researchers and do not reflect the views of NielsenIQ. NielsenIQ is not responsible for, had no role in, and was not involved in analyzing and preparing the results reported herein.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We thank University of California, Berkeley undergraduate students Youssef Andrawis, Ryan Andresen, Anqi Chen, Matthew Chill, Maggie Deng, Amanda Gold, Drake Hayes, Nan Hou, Liam Howell, Hongxian Huang, Zixia Huang, Jason Liu, Julie Maeng, Michael Quiroz, Emaan Saddique, Caroline Wu, Yuemin Xu, April You, Haolin Zhang, and Yihui Zhu for assistance with entering and cleaning the nutritional data and beverage classification.

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SUPPLEMENT 1.
eMethods. Supplemental Methods
eTable 1. Total Coverage of SSB Ounces Sold in Matched Nielsen Retail Scanner Data eTable 2. Total Population (2010) by City within Taxed 3-Digit Zip Codes eTable 3. Two-Way Fixed Effects Estimation Results for Composite and Individual City Analyses eFigure 1. Comparing Treated and Synthetic Values of Prognostic Factors from the Analysis of SSB Shelf Prices eFigure 2. Overlap of US Census Sociodemographic Characteristics Between Each Taxed City and the Donor Pool of Control 3-Digit Zip Codes
eFigure 3. Composite and Individual Locality Price Pass-Through eFigure 4. Composite and Individual Changes in Volume Sales in Adjacent Border Zip Codes eFigure 5. Augmented Synthetic Control Estimates for Individual Locality Changes in Price eFigure 6. Augmented Synthetic Control Estimates for Individual Locality Changes in Volume Sales eFigure 7. Augmented Synthetic Control Estimates of Individual Locality Changes in Volume Sales of SSB Products in Border Areas
eFigure 8. Augmented Synthetic Control Estimates for Composite Changes in Price and Volume Sales of SSB Products (Population Weighted)
eFigure 9. Augmented Synthetic Control Estimates of Composite Changes in Volume Sales of SSB Products in Border Areas (Population Weighted)
eFigure 10. Composite and Individual Locality Demand Elasticity Estimates (Urbanicity > 0.85) eFigure 11. Augmented Synthetic Control Estimates for Composite Changes in Price and Volume Sales of SSB Products (Urbanicity > 0.85)
eFigure 12. Augmented Synthetic Control Estimates of Composite Changes in Volume Sales of SSB Products in Border Areas (Urbanicity > 0.85)
eFigure 13. Composite and Individual Locality Demand Elasticity Estimates (Urbanicity > 0.9) eFigure 14. Augmented Synthetic Control Estimates for Composite Changes in Price and Volume Sales of SSB Products (Urbanicity > 0.9)
eFigure 15. Augmented Synthetic Control Estimates of Composite Changes in Volume Sales of SSB Products in Border Areas (Urbanicity > 0.9)
eFigure 16. TWFE Estimates of Composite Changes in Prices, Volume Sales, and Border Volume Sales eFigure 17. TWFE Estimates of Individual Locality Changes in Prices eFigure 18. TWFE Estimates of Individual Locality Changes in Volume Sales eFigure 19. TWFE Estimates of Individual Locality Changes in Volume Sales of SSB Products in Border Areas SUPPLEMENT 2.

Data Sharing Statement
JAMA Health Forum | Original Investigation Changes in Prices and Purchases Following Implementation of Sugar-Sweetened Beverage Taxes JAMA Health Forum. 2024;5(1):e234737. doi:10.1001/jamahealthforum.2023.4737 (Reprinted) January 5, 2024 12/12 Downloaded from jamanetwork.com by guest on 06/06/2024

41.33 41.34
Dignity Health Dominican Hospital ● 2022 CHNA 38
Healthy Lifestyles (Diabetes & Obesity)
Healthy weight is a significant issue in Santa Cruz County, with a larger proportion of children who are overweight for their age compared to all California children. In addition, adult obesity and overweight are highest among the county’s Latino population, while obese adults are overrepresented among the county’s multiethnic population. Santa Cruz County’s Filipino 5thgraders and Latino 5th- and 9th-graders are less likely to be a healthy weight compared to their county- or statewide peers, but the trends for 5th- and 9th-graders are improving. The percentage of children and teenagers who engage in regular physical activity is trending down (especially in ZIP code 95076).

Children Ages 2-11 Overweight for Age
Source: California Health Interview Survey,
Neighborhood Edition (2017-18).

The food environment is related to residents’ ability to maintain a healthy weight. Fast food expenditures are higher in Santa Cruz County than in California, and expenditures on highsugar foods and beverages are trending upward. Fast food consumption is especially high among the county’s Asian population. The county’s CalFresh enrollment numbers increased substantially between 2019 and 2020, likely signaling a rise in food insecurity due to the pandemic. Finally, the ratio of recreation and fitness facilities in the county compared to the population has been decreasing.

Although neither the statistical data nor the key informants and focus group participants connected diabetes and obesity with health disparities or inequities, experts writing on behalf of the American Diabetes Association describe placing “socioeconomic disparities and the other [social determinants of health] downstream from racism—which we posit is a root cause for disparities in diabetes outcomes in marginalized and minoritized populations.”53 53 Ogunwole, S. M., & Golden, S. H. (2021). Social determinants of health and structural inequities—Root causes of diabetes disparities. Diabetes Care, 44 (1): 11-13. Retrieved from https://care.diabetesjournals.org/content/44/1/11 ͳͶǤͻΨ
ͳͷǤͺΨ

41.35 Dignity Health Dominican Hospital ● 2022 CHNA 141

HEALTHY LIFESTYLES (DIABETES & OBESITY)

INDICATOR NAME PERIOD CA DESIRED

DIRECTION
SCC
RATE
SCC
N/
COUNT
TREND
Adults with Diabetes 2015-2016 9.4 Below 7.5 —
Age-Adjusted Death Rate due to Diabetes 2016-2018 21.2 Below 14.6 Ç Diabetes: Medicare Population 2018 27.2 Below 18.8 ÈS
Diabetic Monitoring: Medicare Population 2015 81.9 Above 87.4 Ç 7th Grade Students who are Physically Fit 2018-2019 61.0 Above 66.6 Ç Access to Exercise Opportunities 2020 93.1 Above 94.0
Adult Fast-Food Consumption 2016 65.6 Below 38.9 È
Adults who Drink Sugar-Sweetened Beverages 2015-2016 11.0 Below 7.4 È Adults who Walk Regularly 2015-2016 38.9 Above 43.4 Ç
Children and Teens who Engage in Regular Physical
Activity
2015-2016 16.5 Above 16.5 È

41.36 Dignity Health Dominican Hospital ● 2022 CHNA 142

INDICATOR NAME PERIOD CA DESIRED

DIRECTION
SCC
RATE
SCC
N/
COUNT
TREND
Ratio of Fitness and Recreation Centers per 1,000
population
2016 0.06US Above 0.13 È
Consumer Expenditures: Fast Food Restaurants 2021 $2,063 Below $2,142 È Food Environment Index 2021 8.8 Above 8.4 Ç
Percent of Consumer Spending: Fruits and
Vegetables
2019 1.45 Above 1.39 Ç
Percent of Consumer Spending: High Sugar
Beverages
2019 0.45 Below 0.42 Ç
Percent of Consumer Spending: High Sugar Foods 2019 0.71 Below 0.68 Ç 5th Grade Students who are at a Healthy Weight or
Underweight
2018-2019 58.7 Above 59.0 Ç
9th Grade Students who are at a Healthy Weight or
Underweight
2018-2019 62.2 Above 64.2 Ç
Adults Who Are Obese 2019 27.3 Below 21.5 Ç
Adults who are Overweight or Obese 2019 59.6 Below 49.3 È

41.37 Dignity Health Dominican Hospital ● 2022 CHNA 143

INDICATOR NAME PERIOD CA DESIRED

DIRECTION
SCC
RATE
SCC
N/
COUNT
TREND
Children who are Overweight for Age 2017-2018 14.9 Below ♦15.8 — Teens who are Overweight or Obese 2015-2016 38.2 Below 11.0 È CalFresh Households 2021 N/A Above 16,204 Ç
Farmers Market Density 2018 N/A Above 0.04 10 ÇS

HEALTHY LIFESTYLES RACE/ETHNICITY DATA

INDICATOR NAME CA
VALUE

DESIRED

DIRECTION
BLACK
/ AFR
ANC
AMER
IND
ASIAN FILIPINO HISP/
LATINO
TWO
OR
MORE
WHITE
5th Grade Students who are at a Healthy
Weight or Underweight

58.7 Above 59.3 72.7 ♦44.4 ♦48.4 73.9 73.4
7th Grade Students who are Physically
Fit

61.0 Above 61.3 81.8 81.0 69.2 59.4 63.2 79.1
9th Grade Students who are at a Healthy
Weight or Underweight

62.2 Above 88.2 85.2 78.6 ♦52.9 75.6 77.5
Adult Fast-Food Consumption 65.6 Below ♦77.6 55.9 40.5 29.8 Adults Who Are Obese 27.3 Below ♦34.7 14.7

41.38 Dignity Health Dominican Hospital ● 2022 CHNA 144

INDICATOR NAME CA
VALUE

DESIRED

DIRECTION
BLACK
/ AFR
ANC
AMER
IND
ASIAN FILIPINO HISP/
LATINO
TWO
OR
MORE
WHITE
Adults who are Overweight or Obese 59.6 Below 55.5 ♦63.0 ♦76.0 40.7 Adults with Diabetes 9.4 Below 7.6 8.9 7.8
Diabetic Monitoring: Medicare Population 81.9 Above 90.5 87.3

HEALTHY LIFESTYLES SUB-COUNTY DATA FINDINGS
Watsonville / 95076
Poor Physical Health: 14+ Days: (also Freedom)
Children and Teens who Engage in Regular Physical Activity (95076 trend worsening only)

41.39 NUTRITION
How Does Liquid Sugar Harm Your Body?
Medically reviewed by Atli Arnarson BSc, PhD — Written by Franziska Spritzler — Updated on January 27, 2020
Added sugar is unhealthy when consumed in excess.

However, liquid sugar may be especially harmful.

Research shows that getting sugar in liquid form is much worse than getting it from solid food. This is why high sugar beverages like soda are among the worst things you can put into your body.

This article explains how liquid sugar affects your weight, blood sugar, and risk of heart disease — and tells you what to consume instead.

Liquid sugar is the sugar you consume in liquid form from beverages like sugar sweetened soda.

The sugar in beverages is often highly concentrated and easy to consume in large amounts without feeling full.

Some examples of these drinks are fairly obvious, such as sodas and fruit punch. However, many other beverages are high in sugar as well.

For instance, although fruit juice is typically considered a healthier option, even varieties without added sugar can be as high in sugar and calories u Evidence Based vidence Based
What it is Liquid vs. solid sugar Weight gain Blood sugar Heart disease Proper intake Alternatives Bottom line

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6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.40 1/12 as sweetened drinks — sometimes even higher.

What’s more, a high intake of fruit juice may lead to the same health problems as drinking sugar sweetened beverages (1 ).

Here are the calorie and sugar contents in 12 ounces (355 mL) of some popular high sugar beverages:

Soda: 151 calories and 39 grams of sugar (2 )
Sweetened iced tea: 144 calories and 35 grams of sugar (3 ) Unsweetened orange juice: 175 calories and 33 grams of sugar (4 ) Unsweetened grape juice: 228 calories and 54 grams of sugar (5 ) Fruit punch: 175 calories and 42 grams of sugar (6 )
Lemonade: 149 calories and 37 grams of sugar (7 )
Sports beverage: 118 calories and 22 grams of sugar (8 )

SUMMARY
Sweet beverages, including unsweetened fruit juice, are high in calories from sugar. Frequently consuming liquid sugar calories may increase your risk of health problems.

A major problem with liquid sugar calories is that your brain doesn’t register them like it does the calories from solid food.

Studies show that drinking calories doesn’t elicit the same fullness signals as eating them. As a result, you don’t compensate by eating less of other foods later on (9 , 10 ).

In one study, people who ate 450 calories in the form of jellybeans ended up eating less later. When they drank 450 calories of soda, they ended up eating many more total calories later in the day (9 ).

Solid and liquid forms of fruit affect hunger levels differently as well.

In a 6-day study, people consumed a whole apple, applesauce, or apple juice. Whether drunk as a meal or snack, apple juice was shown to be the least filling while whole fruit satisfied appetite the most (10 ).

SUMMARY
Liquid sugar is different than solid sugar
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6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.41 2/12 Research shows that your body doesn’t register liquid sugar in the same way as it does solid sugar. This can cause greater appetite and calorie intake later on.

Frequently consuming sugar may promote excessive calorie intake and weight gain.

This may be because it generally contains a high amount of fructose, which is unhealthy when consumed in large amounts.

For example, table sugar contains 50% glucose and 50% fructose, while high fructose corn syrup contains about 45% glucose and 55% fructose.

Research shows that both affect appetite and calorie intake the same way (11 ).

A researcher in a recent review also pointed out that all fructosecontaining sugars — including honey, agave nectar and fruit juice — have the same potential for causing weight gain (12 ).

What’s more, several studies link excess fructose to weight gain. A high intake seems to promote belly fat, which increases disease risk (13 , 14 , 15 , 16 ).

Sodas and other sweet drinks make it easy to consume large doses of sugar and fructose in a very short period of time. As stated above, these calories aren’t adequately compensated for later in the day.

However, even when calorie intake is controlled, a high intake of liquid sugars may lead to an increase in body fat.

In a 10-week study, people with overweight and obesity consumed 25% of calories as fructose-sweetened beverages at a calorie level that should have maintained their weight. Instead, insulin sensitivity decreased and belly fat increased (15 ).

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6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.42 3/12 Although lack of compliance could explain these results, some evidence suggests high fructose intake reduces energy expenditure. A separate analysis found that fat burning and metabolic rate decreased in those who followed this fructose-rich diet for 10 weeks (16 ).

SUMMARY
Several studies have linked liquid sugar calories to weight gain, which may be due to the effects of sugar and fructose on appetite and fat storage.

In addition to promoting weight gain, liquid sugar calories can lead to elevated blood sugar levels and insulin resistance.

Several studies link a high fructose intake to a decrease in insulin sensitivity and increased risk of type 2 diabetes (17 , 18 , 19 ).

Sugary beverages seem to further increase this risk by delivering a large amount of fructose in a short amount of time.

In a detailed analysis of 11 studies in over 300,000 people, those consuming 1–2 sugar-sweetened beverages per day were 26% more likely to develop type 2 diabetes than those who drank 1 or fewer sweetened beverages per month (19 ).

In addition to insulin resistance and diabetes, frequent sugary beverage intake is linked to nonalcoholic fatty liver disease (NAFLD).

When you consume more fructose than your liver can store as glycogen, the extra fructose is converted into fat. Part of this fat get stored in your liver, which may drive inflammation, insulin resistance, and fatty liver disease (20 , 21 ).

Unfortunately, insulin resistance and other health problems related to a high intake of liquid sugars often start as early as childhood and adolescence (22 , 23 ).

SUMMARY
Drinking a lot of liquid sugar may lead to insulin resistance, metabolic syndrome, type 2 diabetes, and fatty liver disease.

Liquid sugar and blood sugar levels

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6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.43 4/12 Liquid sugars also have negative effects on heart health.

Some studies indicate that a high intake of fructose raises your levels of triglycerides and other fat molecules in your bloodstream. High amounts of these fats in your blood increase heart disease risk (13 , 15 , 24 , 25 ).

What’s more, this doesn’t occur exclusively in people who are insulin resistant, have obesity, or have diabetes.

One 2-week study reported that several heart health markers worsened in both young men with overweight and moderate weight who drank large amounts of beverages sweetened with high fructose corn syrup (25 ).

Another study in healthy adults found that even small to moderate doses of sugar sweetened beverages led to unhealthy changes in particle size of LDL (bad) cholesterol and an increase in the inflammatory marker CRP (26 ).

Liquid sugars may be particularly harmful to people who are already insulin resistant or who have overweight.

In the 10-week study that provided 25% of calories as high fructose beverages, people with overweight and obesity experienced increases in small, dense LDL particles and oxidized cholesterol. These are considered major heart disease risk factors (15 ).

However, studies on the effects of fructose on triglycerides and blood lipids have provided inconsistent results and are a matter of debate (27 , 28 ).

SUMMARY
Liquid sugar raises your risk of heart disease
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6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.44 5/12 Consuming liquid sugar calories may lead to inflammation, high blood triglycerides, and changes in LDL (bad) cholesterol that increase heart disease risk.

The more sugar sweetened beverages you drink, the greater your risk of health problems.

In a study that provided between 0–25% of calories from sugar sweetened beverages, those in the 25% group had a greater increase in disease risk factors than the 10% group (25 ).

Only the 0% group experienced no negative effects (25 ).

Another study found that consuming 6.5% of calories as sugar sweetened beverages for 3 weeks negatively affected health markers and body composition in healthy men (26 ).

On a 2,200-calorie diet, this would be about 143 calories — or 1 soda per day.

The amount of liquid sugar that can be consumed without causing health problems varies from person to person. However, limiting fruit juice to 2 ounces (60 mL) per day and completely avoiding other beverages with added sugars is your best option.

SUMMARY
A high intake of liquid sugar is bad for your health. Limit your fruit juice consumption to 2 ounces (60 mL) per day and avoid beverages with added sugar.

Plain water is the healthiest beverage you can drink. However, alternating plain water with beverages that provide a little flavor is more realistic for many people.

Here are a few healthy alternatives to sugar sweetened beverages and fruit juice:
plain or sparkling water with a slice of lemon or lime
iced black or green tea with lemon
How much is too much?
What to drink instead
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6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.45 6/12 iced herbal tea
hot or iced coffee with milk or cream
Most of these beverages are delicious without any added sweetener.

However, if you’re transitioning from sugar-sweetened beverages, you may find it helpful to use one of these natural sweeteners.

Overall, there are many healthy and delicious alternatives to sugary beverages.

SUMMARY
Plain water is the best choice for your health. Other substitutes for soda and sugary beverages include coffee and tea.

Liquid sugar is the sugar that’s contained in any sweet beverage, such as soda, juice, or energy drinks.

Because it doesn’t make you full, it’s prone to have a host of negative effects on your body.

In fact, it’s strongly linked to weight gain, high blood sugar, and heart disease risk. As such, it’s best to limit your intake and drink beverages like plain water, coffee, or tea instead.

Last medically reviewed on January 27, 2020
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11 Reasons Why Too Much Sugar Is Bad for
You
Written by Jillian Kubala, MS, RD
Experts believe that excess sugar consumption is a major cause of obesity and many chronic diseases. Here are 11 negative health effects o…  ADVERTISEMENT
6/5/24, 8:50 PM Liquid Sugar: Calories, Weight Gain, Blood Sugar, and More https://www.healthline.com/nutrition/liquid-sugar-calories#what-it-is 41.46 7/12 Appetite
Volume ƧƩƩ, Ƨ February ƨƦƧƯ, Pages ƧƩƦ-ƧƩƭ
Potentially addictive properties of sugarsweetened beverages among adolescents Jennifer Falbe , Hannah R. Thompson , Anisha Patel , Kristine A. Madsen University of California, Davis, Human Development and Family Studies, Department of Human Ecology, One Shields Ave, Davis, CA, ƯƫƬƧƬ, USA
University of California, Berkeley, Community Health Sciences, School of Public Health, ƨƧƨƧ Berkeley Way, Room ƫƩƦƨ, Berkeley, CA, ƯƪƭƨƦ, USA
Stanford University, Division of General Pediatrics, Lucile Salter Packard Children's Hospital, ƧƨƬƫ Welch Rd, MSOB XƨƪƦ, Mailcode ƫƪƫƯ, Stanford, CA, ƯƪƩƦƫ, USA Received Ʈ February ƨƦƧƮ, Revised ƨƪ October ƨƦƧƮ, Accepted ƨƭ October ƨƦƧƮ, Available online ƨƯ October ƨƦƧƮ, Version of Record Ʃ November ƨƦƧƮ.

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https://doi.org/ƧƦ.ƧƦƧƬ/j.appet.ƨƦƧƮ.ƧƦ.ƦƩƨ
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Abstract
Sugar-sweetened beverages (SSBs) increase risk of cardiometabolic disease. Young people consume the largest amounts of SSBs and have experienced the greatest relative gains in obesity in the past several decades. There is evidence of addictive properties of both caffeine ab c b
a
b
c
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6/5/24, 8:55 PM Potentially addictive properties of sugar-sweetened beverages among adolescents - ScienceDirect https://www.sciencedirect.com/science/article/abs/pii/S0195666318301740 41.47 1/8 and sugar, the primary ingredients in SSBs, but little research into such properties of SSBs in naturally occurring consumption patterns. Thus, in this exploratory study, we sought to examine potentially addictive properties of SSBs during a 3-day SSB cessation intervention in overweight and obese adolescents who typically consume ≥3 SSBs daily. Participants (n = 25) were aged 13–18 years, mostly female (72%), and African American (56%) or Hispanic (16%) with a BMI≥95th percenttile (76%). Withdrawal symptoms and SSB craving were assessed approximately 1-week apart, during both regular SSB consumption and a 3- day period of SSB cessation in which participants were instructed to drink only plain milk and water. During SSB cessation, adolescents reported increased SSB cravings and headache and decreased motivation, contentment, ability to concentrate, and overall well-being (uncorrected Ps < 0.05). After controlling the false discovery rate, changes in motivation, craving, and well-being remained significant (corrected Ps < 0.05). Using 24-hr recalls and drink journals, participants reported lower total daily consumption of sugar (−80 g) and added sugar (−16 g) (Ps < 0.001) during cessation. This study provides preliminary evidence of withdrawal symptoms and increased SSB cravings during cessation in a diverse population of overweight or obese adolescents.

Introduction
Reducing consumption of sugar-sweetened beverages (SSBs) has become a global public health priority (Lobstein, 2017). This is due to strong evidence that SSB consumption increases risk of obesity and cardiometabolic disease (Hu, 2013; Malik, Popkin, Bray, Despres, & Hu, 2010) and the fact that SSBs are the largest contributor to added sugar in the diet across multiple countries (Block, 2004; Brisbois, Marsden, Anderson, & Sievenpiper, 2014; Reedy & Krebs-Smith, 2010; Sanchez-Pimienta, Batis, Lutter, & Rivera, 2016). Excessive SSB consumption is a particular concern among adolescents, who consume more SSBs than any other age group in the U.S. (Kit, Fakhouri, Park, Nielsen, & Ogden, 2013). Adolescents also experienced the greatest relative increase in obesity prevalence, which quadrupled over the past several decades (U.S. Department of Health and Human Services, 2014).

Compared to other foods, SSBs have unique attributes that may promote overconsumption of calories. First, compared to calories from solid food, liquid calories appear to be less satiating and incompletely compensated for by eating fewer calories later in the day (Almiron-Roig et al., 2013; Mattes, 1996). Second, SSBs contain primary ingredients— caffeine and sugar—with evidence of addictive potential. Caffeine withdrawal is an established disorder recognized by the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10) (American Psychiatric Association, 2013; Meredith, Juliano, 6/5/24, 8:55 PM Potentially addictive properties of sugar-sweetened beverages among adolescents - ScienceDirect https://www.sciencedirect.com/science/article/abs/pii/S0195666318301740 41.48 2/8 Hughes, & Griffiths, 2013; World Health Organization, 1992). The continued use of caffeine despite harm (e.g., insomnia, hypertension) has been documented, and caffeine dependence syndrome is recognized by ICD-10 (Meredith et al., 2013; World Health Organization, 1992).

In contrast, research on the addictive potential of sugar is a relatively new but burgeoning area. The majority of such studies have used animal models, which reveal parallels between added sugars and substances of abuse in bingeing, craving, tolerance, and withdrawal (DiNicolantonio, O'Keefe, & Wilson, 2017). Also, human neuroimaging studies show that high sugar intake activates similar neural circuitry and reward systems as substances of abuse (Smith & Robbins, 2013). Although there is an evolutionary rationale for liking sweetness to encourage consumption of nutrient- and energy-containing foods (e.g., mother's milk or fruits), added sugars are distinct in that they are extracted, concentrated, and separated from the nutrients in their original forms (e.g., beets or corn). This extraction and concentration process is akin to that of addictive substances like opium from poppies or ethanol from fruit (Davis, 2014).

Adolescence is a particularly susceptible period for addiction, when still-developing brains are highly sensitive to substances and when risk-taking is more likely due to a faster developing limbic system (which supports emotion) than prefrontal cortex (site of executive control) (IOM (Institute of Medicine) and NRC (National Research Council), 2011). Although still minors, the transition to the teenage years is marked by greater autonomy in food purchasing and more frequent exposure to advertising for SSBs (Powell, Szczypka, & Chaloupka, 2010). In 2009, carbonated beverages were the food category with the highest marketing expenditures for teens, totaling nearly $400 million (Federal Trade Commission, 2012).

Although there is evidence of addictive potential of ingredients in SSBs, there is a dearth of research on such properties of SSBs themselves, particularly among adolescents. However, the five-fold increase in SSB consumption since the 1950's (Economic Research Service, 2017) coupled with still high levels of consumption (Rosinger, Herrick, Gahche, & Park, 2017) despite increased publicity of the associated health consequences, is consistent with the “use despite harm” manifestation of addiction. Given the heavy marketing, consumption, and health consequences of SSBs among youth, determining the extent to which SSBs exhibit addictive properties could have important regulatory, communications, and obesity treatment implications. Thus, in this exploratory study, we sought to examine the extent to which SSBs exhibit potentially addictive properties, namely symptoms of withdrawal and craving, among overweight and obese adolescents who consume high amounts of SSBs.
6/5/24, 8:55 PM Potentially addictive properties of sugar-sweetened beverages among adolescents - ScienceDirect https://www.sciencedirect.com/science/article/abs/pii/S0195666318301740 41.49 3/8 Section snippets
Study design
We employed a single arm intervention trial in which pre-post measurements were taken approximately 1-week apart. During the first 5 days, participants were instructed to continue their usual beverage consumption, followed by a 3-day period of SSB cessation (Fig. 1). A 3-day period was selected to overlap with peak severity for symptoms of caffeine, alcohol, and nicotine withdrawal (Hughes, 2007; Juliano & Griffiths, 2004; Kosten & O'Connor, 2003; Shiffman et al., 2006). This study was approved … Results
Table 1 shows participant baseline characteristics assessed during the usual SSB intake phase. The majority of teens were female (72%), non-Hispanic African American (56%), with a BMI≥95th percentile (76%), and a mother with greater than a high school education (64%).

Fewer than half lived with both parents (44%) and had a father with greater than a high school education (45%). Mean consumption of SSBs was 32 ± 22 fl oz/day with soda accounting for the largest share (42%) of SSBs, followed by… Discussion
In this exploratory study of the potentially addictive properties of SSBs, we detected an increase in symptoms of craving for SSBs and withdrawal among overweight and obese teens during a 3-day period of SSB cessation. The teens, who were regular consumers of SSBs before cessation, reported the following specific withdrawal symptoms during SSB cessation: increased headache; decreased motivation to do work, contentment, and ability to concentrate; and lower ratings of overall wellbeing. After… Conclusion
This exploratory study provides early evidence of potentially addictive properties of SSBs in a diverse population of overweight adolescents. These results, combined with present and future corroborating evidence, could inform clinical practice around helping adolescents reduce SSB intake, have important implications for messaging in public health campaigns, and inform the need for efforts to reduce SSB advertising to youth and SSB availability in and around schools.…
6/5/24, 8:55 PM Potentially addictive properties of sugar-sweetened beverages among adolescents - ScienceDirect https://www.sciencedirect.com/science/article/abs/pii/S0195666318301740 41.50 4/8 Funding
This work was supported by a University of California Office of the President Multi-Campus Research Initiative grant (PI, Elissa Epel). J. Falbe's work was supported in part by the American Heart Association (grant #14POST20140055) and National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (grant #1K01DK113068-01A1). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National… Acknowledgements
We would like to thank the participants who made this research possible, as well as Ely Niroomand and Elena Barbot-Wheaton for their assistance with this study.… Recommended articles
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Food and beverage consumption and food addiction among women in the Nurses' Health Studies
Appetite (ƨƦƧƮ)
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All content on this site: Copyright © ƨƦƨƪ Elsevier B.V., its licensors, and contributors. All rights are reserved, including those for text and data mining, AI training, and similar technologies. For all open access content, the Creative Commons licensing terms apply. 6/5/24, 8:55 PM Potentially addictive properties of sugar-sweetened beverages among adolescents - ScienceDirect https://www.sciencedirect.com/science/article/abs/pii/S0195666318301740 41.54 8/8

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41.93 Introduction
Over the last two decades, the sugary drink landscape has been changing. Between a plethora of new drinks on the market and reported changes in beverage sales, many people are confused or concerned about the current state of sugary drink sales and consumption patterns. This report describes the consumption and sales of sugary drinks in the United States over time and among demographic subgroups. Specifically, the report defines sugary drinks, describes health issues related to sugary drink consumption, and answers questions about how many sugary drinks are being consumed in the US and whether consumption patterns differ by age, race/ethnicity, and income.

HEALTHY FOOD AMERICA | Report
.Ū 2018 | www.healthyfoodamerica.org
Healthy Food America | Sugary Drinks in America | .Ū765> 1 Sugary Drinks in America:

Who's Drinking What and How Much?
Key Points
- A majority of Americans consume at least one sugary drink on a given day. - Overall, sugary drink consumption has decreased from its peak in 2000 but flattened in recent years. While the most recent self-reported consumption data show that consumption may have dropped between 2012 and 2014, industry sales data do not show a recent decline. More current self-report data and additional sales data are needed to confirm whether or not sugary drink consumption is trending downward again.
- Sales and consumption of sugary soda and fruit drinks are down, while other categories such as sports drinks, energy drinks, teas, and coffee are increasing, partially mitigating the large soda decline. However, soda is still the dominant sugary drink, making up 65 percent of sugary drink sales. Consumption and sales of diet beverages are also in decline. - Sugary drink consumption varies by age, race/ethnicity, and income:
• Adolescents and young adults are the heaviest consumers of sugary drinks.

Even young infants and toddlers drink a lot of sugary drinks, primarily fruit drinks. • Consumption has gone down in all age groups, with largest declines in 2-5 year olds and 12-19 year olds.
• Differences by race/ethnicity are larger in adults than in children. White adults are less likely to consume sugary drinks on a given day and consume fewer calories from sugary drinks than Black or Hispanic adults. While White children are less likely to drink sugary drinks on a given day than Black or Hispanic children, calories consumed from sugary drinks by children do not vary much by race/ethnicity. Asian American children and adults are the least likely to consume sugary drinks.
• Low-income Americans consume more sugary drinks than those with higher incomes. This disparity has persisted over time, and the gap may be widening by some measures.

41.94 What are sugary drinks?
A “sugary drink” is any beverage that contains added sugars or other caloric sweeteners, including soda, fruit-flavored drinks, flavored water, sports drinks, energy drinks, and sweetened coffee and tea.

Flavored waters without sugar, plain or sparkling water, and 100% fruit juice are not considered sugary drinks because they do not contain any added sugars. Diet drinks that are sweetened with artificial or other no-calorie sweeteners are also not considered sugary drinks, because they do not contain caloric sweeteners. Drinks that contain both no-calorie sweeteners and caloric sweeteners are sugary drinks.

Report
Healthy Food America | Sugary Drinks in America | .Ū765> 2 How much sugar is in that drink?

3.25 tsp

3.5 tsp

6.75 tsp

7.75 tsp

9.75 tsp 8.5 tsp 8.25 tsp
Capri Sun
Fruit Punch
6-oz pouch
Sunny D
8-oz glass
Red Bull

8.3-oz can
Starbucks
Frappuccino

9.5-oz bottle
Coca-Cola
20-oz bottle
Snapple
Peach Tea
16-oz bottle
Gatorade
20-oz bottle
Vitamin
Water
20-oz bottle

16.25 tsp

41.95 Why worry about sugary drinks?
Sugary drinks are uniquely harmful to
health. Sugary drinks, thanks to
their high added sugar content, are
major culprits in the obesity and
diabetes epidemics. They are
associated with numerous other
medical conditions, such as high
blood pressure, heart disease, and
cavities. When sugar is consumed in
a liquid form, it bypasses the body’s
defense against taking in too many
calories; in other words, sugary drinks
don’t make you feel full. These
beverages offer little to no nutritional
benefits, and the extra calories and
sugar in these drinks outweigh any
health benefits from added vitamins.

Sugary drinks also replace healthier
foods in the diet.

There is no doubt that sugary drinks
are driving America’s overconsumption
of added sugars and adding calories to
the diet. Sugary drinks represent almost
half of all added sugars that Americans
consume (see Figure 1). Just one 20-oz.

Coca-Cola has over 16 teaspoons of sugar,
which is well over the maximum of 12 teaspoons per day of added sugars recommended for a healthy diet by the 2015 Dietary Guidelines for Americans and the World Health Organization. Sugary drinks may also be driving the obesity epidemic by contributing extra empty calories to Americans’ diets – daily calorie intake among Americans increased by about 300 calories between 1979 and 2001, and 43 percent of those extra calories came from sugary drinks.1 How much are we drinking?
In 2015, there were enough sugary drinks for sale in the US for every American to drink 44 gallons, or more than 15 ounces every day.2 Fifteen ounces of Coca-Cola translates into an extra 175 calories, which is slightly less than the maximum number of calories from all added sugars recommended in the Dietary Guidelines for Americans.

Globally, the US ranks third in the world for sales of sugary drinks (see Figure 2), and is the world leader for consumption of added sugars.

Report
Healthy Food America | Sugary Drinks in America | .Ū765> 3 Figure 1. Sugary drinks are the key driver of our
overconsumption of added sugars
Sugary Drinks
46%
31%
8%
4%
6%
Source: 2009-2010 data from US Department of Health and Human Services and US Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015.
2%
1% 1% 1%
Alcoholic Beverages Vegetables Fruits & Fruit Juice
Snacks & Sweets Grains Dairy Mixed Dishes
Condiments, Gravies, Spreads, Salad Dressing
Sugary Drinks

41.96 How many calories per day are we drinking from sugary drinks? According to data from a national dietary survey (National Health and Nutrition Examination Survey – NHANES), average calories per person per day from sugary drinks quadrupled between 1965 and 2000.

Sugary drink calories have been declining since then, but this decline has not been steady. Consumption dropped sharply from about 2004 to 2008, but seemed to level off after 2008 (see Figure 3).

Report
Healthy Food America | Sugary Drinks in America | .Ū765> 4 Figure 2. Sales of sugary drinks by country, calories per person per day Chile
Mexico
United States
Argentina
Saudi Arabia
Germany
Netherlands
Canada
Australia
Poland
United Arab Emirates
Denmark
Czech Republic
Portugal
Peru
New Zealand
Turkey
Sweden
UK
Hungary

I I I I I I I I I I I
0 20 40 60 80 100 120 140 160 180 200
Calories sold per person per day
Source: Popkin and Hawkes, 2016
How do we measure sugary drink consumption?
There are three widely used and complementary measures of consumption of sugary drinks:
- Calories consumed per day per person from sugary drinks. This measure describes the contribution of sugary drinks to the overall diet. It is derived from either nutrition surveys (self-report) or industry sales data.
- The proportion of people consuming a sugary drink on a given day. This measure describes how widespread consumption is across a population. It is obtained by asking people about sugary drink consumption in the past 24 hours in a survey.
- The volume of sugary drinks sold per person. This measure describes the amount of sugary drinks sold (and presumably consumed) based on industry sales data.

41.97 Report
Healthy Food America | Sugary Drinks in America | .Ū765> 5 These most recent self-reported survey data suggest that consumption is starting to drop again, but this drop is not reflected in industry sales data. Industry data show that calories from sugary drinks have remained around 175 calories per person per day since 2012 (see Figure 4). While it is unclear why these two data sources show different trends, what is clear is that Americans are still consuming too many calories from sugary drinks.3
Figure 4. Trends in calories per person per day from sugary drinks, 2000 to 2015, self-reported vs. industry sales
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 250 –
225 –
200 –
175 –
150 –
125 –
100 –
75 –
50 –
25 –
0 –
Calories per person per day
Industry sales Adults 20+ years old (self-reported) Children 2-19 years old (self-reported) 200198196195193191189187185184182180178175177177
It is also important to note that these numbers are the average number of calories per person per day, but not everyone in the US drinks sugary drinks every day. About half of adults and two-thirds of children consume sugary drinks on a given day, and the number of calories consumed per day by those who are actually drinking sugary drinks is nearly 350 calories.4 Sources: Beverage Digest Fact Book, 2016; Kit et al; 2013; Bleich et al, 2017 Figure 3. Trends in calories per person per day from sugary drinks, 1965-2014

I I I I I I I I I I I I I I
1965 1968 1972 1976 1980 1984 1988 1992 1996 2000 2004 2008 2012 2014 250 –
225 –
200 –
175 –
150 –
125 –
100 –
75 –
50 –
25 –
0 –
Calories per person per day
Adults 20+ years old
Children 2-19 years old
Sources: National Health and Nutrition Examination Survey (NHANES): Duffey and Popkin, 2007; Kit et al, 2013; Bleich et al, 2017; Wang et al, 2008

41.98 Report
Healthy Food America | Sugary Drinks in America | .Ū765> 6 How many people consume a sugary drink on a given day?
The proportion of children consuming sugary drinks has gone down substantially since the early 1990s when about 80 percent of children were drinking sugary drinks on a given day, but the decline for adults has been slower (see Figure 5).
1988-1994 1999-2002 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 Adults 20+ years old Children 2-19 years old
73% 74%
70% 71%
64%
80% 80% 80%
50%
56% 56% 59% 57%
62% 63%
58%
100% –
90% –
80% –
70% –
60% –
50% –
40% –
30% –
20% –
10% –
0 –
Figure 5. Trends in percent of children and adults consuming sugary drinks on a given day, 1988-1994 to 2013-2014
Sources: (NHANES) Kit et al, 2013; Bleich et al, 2017; Wang et al, 2008

41.99 Report
Healthy Food America | Sugary Drinks in America | .Ū765> 7 What kind of sugary drinks are we drinking?
Soda is the most consumed sugary drink.

Soda availability has risen dramatically since the 1950s - at its peak in 1998, the volume of soda for sale was quadruple that of 1947. While soda sales have been declining since 2000, the decline has slowed down more recently, suggesting there is still more work to do to bring sales and consumption down to healthier levels (see Figure 6).

I I I I I I I I I I I I I I
1947 1952 1957 1962 1967 1972 1977 1982 1987 1992 1997 2002 2007 2012 45 –
40 –
35 –
30 –
25 –
20 –
15 –
10 –
5 –
0 –
Gallons per person per year
1947

10.8 gallons
Peak 1998

40.7 gallons
2015

28.6 gallons
Availability today is
nearly triple what it
was 70 years ago
Figure 6. Availability of regular soda, 1947-2015
Sources: 1947-1983: United States Department of Agriculture, Economic Research Service Food Availability (Per Capita) Data System;1984-2015:

Beverage Marketing Corporation, 2016

41.100
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 8 Soda isn’t the only sugary drink on the market.

As consumers get the message about the health harms of soda, they are turning to other sugary drinks that are marketed as healthier alternatives to soda. Beverage companies, in response, are creating new drinks all the time to fill the sales void left by soda. Sales of sports drinks, energy drinks, bottled coffees and teas, and “value-added” waters have been rising in the past decade (see Figure 7).

These trends have resulted in decreases in the proportion of sugary drink sales from soda and fruit drinks and increases in the contributions from sports drinks, teas, and other sugary drinks.

As a result, total sugary drink sales have only gone down 12 percent since 2000, even though soda sales have decreased nearly 30 percent.5
Figure 7. Trends in sales of non-soda sugary drinks, 2000 to 2015 2000 2003 2006 2009 2012 2015
Year

8.0 –

7.0 –

6.0 –

5.0 –

4.0 –

3.0 –

2.0 –

1.0 –

0.0 –
Gallons per person per year
Fruit drinks Sports Drinks Bottled tea Value-added water Energy drinks Bottled coffee Source: Beverage Marketing Corporation, 2015

41.101
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 9 Today, regular soda (not including diet) remains the most popular sugary drink, making up about 65 percent of the sugary drinks sold in the US, followed by fruit drinks (10 percent), sports drinks (9 percent), and bottled teas (8 percent). Value-added water (with added sugars) (3 percent), energy drinks (4 percent) and bottled coffee (1 percent) comprise a much smaller proportion of sales (see Figure 8).

Figure 8. Trends in sales of sugary drinks in the US, 2000 to 2015 Source: Beverage Marketing Corporation, 2015
2000 2003 2006 2009 2012 2015
60 –
50 –
40 –
30 –
20 –
10 –
0 –
Bottled coffee (1%)
Energy drinks (4%)
Value-added water (3%)
Bottle tea (8%)
Sports drinks (9%)
Fruit drinks (10%)
Regular soda (65%)
Gallons per person per year
(%) = proportion
of sales in 2015

41.102
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 10 Data from a national dietary survey (NHANES) confirms that consumption of soda and fruit drinks (as measured by calories per person per day) has declined since 2003 in children and adults and that soda consumption has not been declining as much in recent years, especially among adults. The most recent decline in calories from sugary drinks was driven by a drop in fruit drink consumption (see Figure 9).

Figure 9. Trends in calories per person per day from sugary drinks, by drink type, 2003-2004 to 2013-2014
Source: (NHANES) Bleich et al, 2017
2003- 2005- 2007- 2009 2011- 2013-
2004 2006 2008 2010 2012 2014
250 –
225 –
200 –
175 –
150 –
125 –
100 –
75 –
50 –
25 –
0 –
Calories per person per day
Other SSB Low calorie SSB Sports drinks Fruit drinks Soda Adults 20+ years old Children 2-19 years old
2003- 2005- 2007- 2009 2011- 2013-
2004 2006 2008 2010 2012 2014

41.103
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 11 Who is drinking sugary drinks?
The data above show overall sugary drink consumption among all Americans, but consumption varies substantially by age, gender, race/ethnicity, and income.

Differences by age and gender
Sugary drink consumption starts very early in the US - more than 30 percent of one-year-olds (12-23 months) consume sugary drinks on a given day and nearly half of all preschool children (2-5 year olds) consume sugary drinks on a given day. Children, adolescents, and young adults are by far the heaviest consumers of sugary drinks. Among 12-19 year olds, 63-67 percent consume sugary drinks on a given day compared to only 38-41 percent among people 60 years and older (see Figure 10).

The proportion of men and women who consume sugary drinks is not significantly different, except among 20-39 year olds. In this age group, significantly more men consume sugary drinks than women (65 percent vs. 57 percent) (see Figure 10).

Early eating patterns set the course for lifelong preferences and habits, so it’s alarming that every day nearly a third of children ages 12–23 months consume sugary drinks.

Figure 10. Percent of males and females consuming sugary drinks on a given day, by age, 2013-2014 2-5 years 6-11 years 12-19 years 20-39 years 40-59 years 60+ years 50%
44%
65% 62%
67% 63% 65%
57%
50% 44% 43% 41%
Males Females
Source: (NHANES) Bleich et al, 2017

41.104
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 12 Calories from sugary drinks have been declining among all age groups, but especially among people under 40 years old. The greatest declines are among 2-5 year olds and 12-19 year olds – they both are drinking about half as many calories from sugary drinks as they were in 2003. Significant declines in calories consumed have also occurred among 6-11 year olds and 20-39 year olds (40 percent and 33 percent less, respectively) (see Figure 11).
325 –
300 –
275 –
250 –
225 –
200 –
175 –
150 –
125 –
100 –
75 –
50 –
25 –
0 –
2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 Calories per person per day
2-5 years 6-11 years 12-19 years 20-39 years 40-59 years 60+ years 297
283
191
176
125
75 190
146
131
114
68 64
Figure 11. Trends in calories per person per day from sugary drinks, by age, 2003-2004 to 2013-2014 Source: (NHANES) Bleich et al, 2017

41.105
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 13 However, adolescents and young adults are still the heaviest consumers of sugary drinks, and nearly 10 percent of their daily calories are coming from sugary drinks alone (see Figure 12).

Figure 12. Percent of total daily calories from sugary drinks,by age and gender, 2011-2014 Sources: (NHANES) Rosinger et al. NCHS data brief, no 271, 2017; Rosinger et al, data brief, no 270, 2017. 2-5 years 6-11 years 12-19 years 20-39 years 40-59 years 60+ years 4.0% 6.6% 5.8% 9.3% 9.7% Males Females
12%
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%

4.1%

9.3%8.2%6.6%6.2%3.8%3.3%
Dietary Guidelines for Americans recommended maximum for ALL added sugars

41.106
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 14 Nearly 10 percent of calories consumed by teenagers and young adults come from sugary drinks, meaning that they are nearly exceeding the Dietary Guidelines recommended maximum for total added sugars from sugary drinks alone.

Children and adults get their sugary drink calories from different types of beverages. Fruit drinks are by far the largest source of sugary drink calories for preschool children (2-5 years old). Soda and fruit drinks are about equal for 6-11 year olds, and soda is the largest source of calories for age groups over 12 years old. Sweetened tea and coffee are significant sources of calories for older adults (see Figure 13).

Figure 13. Proportion of calories from different types of sugary drinks by age, 2005-2012 Source: National Health and Nutrition Examination Survey (NHANES) HFA, 2017 Sweet coffee
Energy drinks
Sweet tea
Sports drinks
Fruit drinks
Soda
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
2-5 years 6-11 years 12-19 years 20-29 years 30-39 years 40-49 years 50-59 years 60+ years

41.107
Report
Healthy Food America | Sugary Drinks in America | .Ū765> 15 One reason consumption of sugary drinks remains high among children is that industry marketing has succeeded in convincing some parents that sports and fruit drinks are healthy beverages.

Many parents believe sports and fruit drinks are healthy – One-fifth believed sports drinks are “good, healthy drinks for children” – One-third believed children need sports drinks for hydration – More than one-quarter believed fruit-flavored drinks are somewhat/very healthy Parents are likely to provide children and youth with sugary drinks – 77 percent reported providing their children with fruit-flavored drinks – 62 percent reported providing their children with soda – 51 percent reported providing their children with sports drinks Zytnick et al, 2016; Munsell et al, 2016
RELATED: Check out HFA’s research brief on fruit juice: Is 100% fruit juice as harmful as drinks with added sugar?
Differences by race/ethnicity
There is variation in sugary drink consumption by race/ethnicity, and the disparities are stronger among adults than children. First we describe variation in consumption of sugary drinks on a given day and then in calories consumed per day.

Consumption among infants and toddlers varies by race/ethnicity. Significantly more Black and Mexican American infants and toddlers (0-24 months) consume sugary drinks on a given day than White children (see Figure 14).

Figure 14. Percent of infants and toddlers (0-24 months) consuming sugary drinks on a given day, by race/ethnicity and by income,* 2005-2012
30%
25%
20%
15%
10%
5%
0%
White Black Mexican Other
American
Race/Ethnicity
15%
23%
26%
14%
Low Low-middle High-middle High
Income level
24%
18% 19%
10%
*Income level is defined by
poverty-income ratio (PIR):

Low income = 0-100% PIR;
Low-middle income =
100-190% PIR;
High-middle income = 200-349%
PIR; High income = >350% PIR
Source: (NHANES) Grimes et al,
2017

41.108
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Healthy Food America | Sugary Drinks in America | .Ū765> 16 White children are significantly less likely to consume sugary drinks on a given day than Black, Mexican American, and Other Hispanic children (see Figure 15). There have been significant declines in the percent of children in each of these groups consuming sugary drinks on a given day, but Black children have made the least progress (about 10 percent less since 2003 compared to about 25 percent less for White, Mexican American, and other Hispanic children) (see Figure 16) White adults are also significantly less likely to drink sugary drinks on a given day than Black, Mexican American, or other Hispanic adults (see Figure 15). Since 2003, White adults have seen the greatest decline in percent consuming sugary drinks on a given day (21 percent less compared to 15 percent less for Black adults and about 8 percent less for Mexican American and other Hispanic adults) (see Figure 16).

Children 2-19 years
80%
60%
40%
20%
0%
Adults 20+ years
White African American Mexican American Other Hispanic
58% 74% 67% 67% 46% 65% 68% 67%
Figure 15. Percent of children and adults consuming sugary drinks on a given day, by race/ethnicity, 2013-2014
Figure 16. Percent of children and adults consuming any surgary drinks on a given day, by race/ethnicity, 2003-2014
Source: (NHANES) Bleich et al, 2017
90%
80%
70%
60%
50%
40%

84.9%

84.2%
Children 2-19 years old Adults 20+ years old
Source: (NHANES) Bleich et al, 2017

86.5%

78.3%

67.0%

73.6%

66.6%

58.0%

73.9%

76.3%

63.7%

57.8%

67.8%

64.9%

58.3%

45.5%
2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 White Black Mexican American Other Hispanic

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Healthy Food America | Sugary Drinks in America | .Ū765> 17 Overall, Asian American children and adults consume the least calories from sugary drinks. White adults consume significantly fewer sugary drink calories than Black and Hispanic adults, but there are no significant differences between White, Black, and Hispanic children (see Figure 17).

Among Black children, girls consume significantly more calories from sugary drinks than boys. Among White adults, men consume significantly more calories from sugary drinks than women (see Figure 17).

Figure 17. Percent of total daily calories from sugary drinks among children and adults, by race/ethnicity and gender, 2011-2014
Source: Rosinger et al, 2017, NCHS data briefs 270 and 271 White Black Asian Hispanic
Children 2-19 years
11%
10%
9%
8%
7%
6%
5%
4%
3%
2%
1%
0%

7.6%7.5%7.9%8.9%3.5%

3.6%7.3%

6.8%
White Black Asian Hispanic
Adults 20+ years

6.4%5.4%8.3%8.9%4.0%3.0%

8.1%

7.4%
Males Females
Dietary Guidelines for Americans recommended maximum for ALL added sugars

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Healthy Food America | Sugary Drinks in America | .Ū765> 18 White, Black, Hispanic, and Mexican American children are all consuming fewer calories from sugary drinks (about 30-50 percent less) than they were in 2003 (see Figure 18). Among adults, White adults consume significantly fewer calories per person per day than Black or Mexican American adults, and this disparity has remained consistent over time. Adults of all races/ethnicities have had less of a decline in calories from sugary drinks than children since 2003 (see Figure 18).

Figure 18. Trends in calories per person per day from sugary drinks, by age and race/ethnicity, 2003-2004 to 2013-2014
Source: (NHANES) Bleich et al, 2017
275 –
250 –
225 –
200 –
175 –
150 –
125 –
100 –
75 –
50 –
25 –
0 –
2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 Calories per person per day
152
149
138
118
232
230
206
2003-2004 2005-2006 2007-2008 2009-2010 2011-2012 2013-2014 123
176
192
260
161
185 180
247
Children 2-19 years old Adults 20+ years old
White Black Mexican American Other Hispanic
238

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Healthy Food America | Sugary Drinks in America | .Ū765> 19 There is variation in the type of sugary drinks consumed among different races/ethnicities – most notably, Black people consume a much larger proportion of sugary drink calories from fruit drinks than White, Mexican American, or Hispanic people (see Figure 19).

Figure 19. Proportion of calories from sugary drinks per person,by race/ethnicity, 2005-2012 Source: (NHANES) HFA, 2017
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
White Black Mexican Other Hispanic
American
Sweet milk
Sports drinks
Energy drinks
Sweet tea
Sweet coffee
Fruit drinks
Soda
Differences by income
More low-income Americans consume sugary drinks on a given day than high income (60 percent vs. 45 percent) (see Figure 20), and this translates to about 35 percent more calories per person per day from sugary drinks among low-income people than higher-income people (236 vs. 140 calories) (see Figure 21). This disparity has persisted over the past decade, and some metrics show that it may be widening. In particular, the percent of “heavy consumers” (people drinking 3 or more servings of sugary drinks on a given day) among low-income people has remained relatively stable, while dropping nearly 25 percent among higher-income people.7 There are no major differences in the type of sugary drinks consumed by income level; soda is the largest contributor of sugary drink calories in all income levels.

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Healthy Food America | Sugary Drinks in America | .Ū765> 20 Figure 20. Trends in percent consuming sugary drinks on a given day, by income level,* 2005-2006 to 2011-2012
*Income level is defined by poverty-income ratio (PIR): Low income = 0-185% PIR; Middle income = 186-400% PIR; High income = >400% PIR Source: (NHANES) HFA, 2017
70% –
60% –
50% –
40% –
30% –
20% –
10% –
0% –
Low income Middle income High income
2005-2006 2007-2008 2009-2010 2011-2012

60.2%

45.6%

60.4%

44.8%

54.1%

57.4%
Figure 21. Trends in calories per person per day, by income level,* 2005-2006 to 2011-2012 *Income level is defined by poverty-income ratio (PIR): Low income = 0-185% PIR; Middle income = 186-400% PIR; High income = >400% PIR Source: (NHANES) HFA, 2017
250 –
225 –
200 –
175 –
150 –
125 –
100 –
75 –
50 –
25 –
0 –
Calories per person per day
Low income Middle income High income
2005-2006 2007-2008 2009-2010 2011-2012
238
165
236
140
186
208

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Healthy Food America | Sugary Drinks in America | .Ū765> 21 What is the Role of Marketing?
The overconsumption of sugary drinks is in part driven by industry spending on marketing. In 2017, the beverage industry spent over 1.2 billion dollars in marketing, with 45 percent dedicated to marketing full-sugar carbonated drinks.8 Beverage marketing is often targeted towards young people, low-income individuals, and people of color. In 2013, Black youth saw more than twice as many television ads for sugary drinks and energy drinks as White youth.9 This targeted marketing may contribute to inequities in sugary drink consumption and the associated chronic health problems.

What can we do to reduce consumption of sugary drinks?
While the ultimate goal is to decrease consumption of added sugars from food and drinks, focusing on sugary drinks is a good first step since they are the number one source of added sugars in Americans’ diets. While there are many ways to approach this challenge, some core strategies have been gaining popularity in the US and around the world. Below is a list of these strategies and links to further information about each strategy.

Core sugary drink strategies:

Affordability—Make sugary drinks more expensive to produce or buy. • Taxing sugary drinks
• Changing institutional pricing
Acceptability/Appeal—Engage in counter-advertising and education and limit marketing. • Public awareness campaigns
• Warning labels
• Nutrition facts
• Marketing restrictions
Availability—Reduce the availability of sugary drinks.
• Removing sugary drinks from institutional settings (hospitals, schools, government, etc.) • Removing sugary drinks from kid’s meals
• Reducing the amount of sugar found in beverages (product reformulation) • Reducing the portion sizes of sugary drinks: by regulation (e.g. proposal [not adopted] from New York City) or by industry voluntary action.

For more ideas on how to reduce exposure to added sugars, see Six Key Policies aimed at both foods and drinks.

41.114
References
Beverage Digest. Beverage digest fact book. Available at https://www.beverage-digest.com/factbook. Published 2015. Accessed 2016.

Beverage Marketing Corporation. Non-alcoholic beverage trend analysis. 2015.

Bleich SN, Vercammen KA, Koma JW, Li Z. Trends in beverage consumption among children and adults, 2003-2014. Obesity. 2017;26(2):432-441.

Duffey KJ, Popkin BM. Shifts in patterns and consumption of beverages between 1965 and 2002. Obesity. 2007;15(11):2739-2747.

Grimes CA, Szymlek-Gay EA, Nicklas TA. Beverage consumption among US children aged 0-24 Months:

National Health and Nutrition Examination Survey (NHANES). Nutrients. 2017;9(3): 264.

Harris JLS, Schwartz MB, Shehan C, et al. SnackFACTS 2015.

University of Connecticut Rudd Center for Food Policy and Obesity. http://www.uconnruddcenter.org/files/Pdfs/SnackFACTS_2015_Fulldraft03.pdf. Published 2015.

Accessed April 24, 2018.

Healthy Food America. NHANES 2005-2012 analysis. Unpublished data. 2017.

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;98:180-188.

Munsell CR, Harris JL, Sarda V, Schwartz MB. Parents' beliefs about the healthfulness of sugary drink options:
opportunities to address misperceptions. Public Health Nutr. 2016;19(1):46-54.

Park S, McGuire LC, Galuska DA. Regional differences in sugar-sweetened beverage intake among US Adults.

J Acad Nutr Diet. 2015;115(12):1996-2002.

Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol. 2016;4(2):174-86.

Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among US adults, 2011-2014.

NCHS Data Brief. 2017(270):1-8.

Rosinger A, Herrick K, Gahche J, Park S. Sugar-sweetened beverage consumption among US youth, 2011-2014.

NCHS Data Brief. 2017(271):1-8.

University of Connecticut Rudd Center for Food Policy and Obesity. Unpublished analysis of Nielsen Data. 2018.

US Department of Health and Human Services and US Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 2015; 8th Edition. https://health.gov/dietaryguidelines/2015/guidelines/. Published December 2015. Accessed April 24, 2018.

Wang YC, Bleich SN, Gortmaker SL. Increasing caloric contribution from sugar-sweetened beverages and 100% fruit juices among US children and adolescents, 1988-2004. Pediatrics. 2008;121(6):e1604-1614.

Woodward-Lopez G, Kao J, Ritchie L. To what extent have sweetened beverages contributed to the obesity epidemic? Public Health Nutr. 2011;14(3):499-509.

Zytnick D, Park S, Onufrak SJ. Child and caregiver attitudes about sports drinks and weekly sports drink intake among US youth. Am J Health Promot. 2016;30(3):e110-119.

Report
Healthy Food America | Sugary Drinks in America | .Ū765> 22 41.115 Notes

1. Woodward-Lopez et al, 2011

2. Beverage Marketing Corporation, 2015 – This total includes sugary drinks only and excludes diet drinks and 100% fruit juice

3. The major difference between the two data sources is that the national survey is based on a self-report of sugary drink consumption from a sample of Americans, while the industry data is based on the total volume of sugary drinks sold in the US, divided by the total population. Industry data also includes calories from 100% fruit juice, which are not included in the national survey data (because 100% fruit juice is not considered a “sugary drink”)

4. Healthy Food America (2017), NHANES 2005-2012. Unpublished data

5. Beverage Marketing Corporation, 2015

6. Grimes et al, 2017

7. (NHANES) HFA, 2017

8. University of Connecticut Rudd Center for Food Policy and Obesity (2018). Nielsen. Unpublished Data.

9. Harris et al, 2015
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Healthy Food America | Sugary Drinks in America | .Ū765> 23 41.116 Circulation. 2017;135:e1017–e1034. DOI: 10.1161/CIR.0000000000000439 May 9, 2017 e1017

CLINICAL STATEMENTS

AND GUIDELINES
BACKGROUND: Poor lifestyle behaviors are leading causes of preventable diseases globally. Added sugars contribute to a diet that is energy dense but nutrient poor and increase risk of developing obesity, cardiovascular disease, hypertension, obesity-related cancers, and dental caries.

METHODS AND RESULTS: For this American Heart Association scientific statement, the writing group reviewed and graded the current scientific evidence for studies examining the cardiovascular health effects of added sugars on children. The available literature was subdivided into 5 broad subareas: effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity.

CONCLUSIONS: Associations between added sugars and increased cardiovascular disease risk factors among US children are present at levels far below current consumption levels. Strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia. The committee found that it is reasonable to recommend that children consume ≤25 g (100 cal or ≈6 teaspoons) of added sugars per day and to avoid added sugars for children <2 years of age. Although added sugars most likely can be safely consumed in low amounts as part of a healthy diet, few children achieve such levels, making this an important public health target.

Miriam B. Vos, MD,
MSPH, FAHA, Chair
Jill L. Kaar, PhD
Jean A. Welsh, PhD, MPH,
RN
Linda V. Van Horn, PhD,

RD, FAHA
Daniel I. Feig, MD, PhD
Cheryl A.M. Anderson,
PhD, MPH, MS, FAHA
Mahesh J. Patel, MD
Jessica Cruz Munos, MD
Nancy F. Krebs, MD, MS
Stavra A. Xanthakos, MD,
MS
Rachel K. Johnson, PhD,

MPH, RD, FAHA
On behalf of the American
Heart Association Nutrition Committee of the
Council on Lifestyle and
Cardiometabolic Health;
Council on Clinical
Cardiology; Council on
Cardiovascular Disease
in the Young; Council
on Cardiovascular and
Stroke Nursing; Council
on Epidemiology and
Prevention; Council
on Functional Genomics and Translational
Biology; and Council on
Hypertension
Added Sugars and Cardiovascular Disease
Risk in Children
A Scientific Statement From the American Heart Association © 2016 American Heart
Association, Inc.

Key Words: AHA Scientific
Statements ◼ child ◼ diet
◼ nutritional status ◼ obesity
◼ sugar ◼ sweetening agents

AHA SCIENTIFIC STATEMENT
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41.117
Vos et al
e1018 May 9, 2017 Circulation. 2017;135:e1017–e1034. DOI: 10.1161/CIR.0000000000000439 Atherosclerotic cardiovascular disease (CVD) is the
leading cause of death in North Americans and
generates tremendous personal and economic
burden globally. Efforts to reduce the prevalence of CVD and its associated conditions (obesity, hypertension,
type II diabetes mellitus, and nonalcoholic fatty liver disease [NAFLD]) have focused attention on the role of diet and the growing evidence that atherosclerosis starts in childhood.1–3 Accumulating evidence implicates dietary
sugars, particularly those added to processed foods or
used in the preparation of foods and beverages. In part because of the lack of clarity and consensus on how
much sugar is considered safe for children, sugars remain a commonly added ingredient in foods and drinks, and overall consumption by children and adults remains
high. Although intake of added sugars has decreased
slightly in recent years,4 they still contribute nearly 16% of the calories consumed by US children daily (Table 1).

The purposes of this statement are to review the
available evidence on added sugars intake and CVD risk
in children and adolescents, to identify research gaps, and to make recommendations on the consumption of
added sugars intake to reduce CVD risk.

APPROACH
The writing group members conducted literature
searches for each section using relevant search terms,
including sugar, fructose, added sugars, dietary, sugarsweetened beverages, sweeteners, children, noncaloric sweeteners, artificial sweeteners, nonnutritive sweeteners, diabetes mellitus, insulin resistance, triglycerides, lipids, cardiovascular disease, cardiovascular risk, uric acid, hypertension, blood pressure, allopurinol, liver, steatohepatitis, nonalcoholic fatty liver disease, and inflammation. The PubMed searches were limited to original research, studies conducted in humans, and systematic
reviews through November 2015. The reference lists of
relevant articles were reviewed for additional articles.

The articles were summarized, and the summaries were
discussed during conference calls among the topic area
experts who were part of the writing group. Group consensus was used to develop recommendations (Table 2).

To provide the most up-to-date estimates of added
sugar consumption in the United States, dietary data
from the NHANES (National Health and Nutrition Examination Survey) 2009 to 2012 were analyzed. NHANES data are collected and made publically available by the National Center for Health Statistics. The analytical methods used replicate5 those used by Welsh et al in their analysis of NHANES data from 1999 through 2008.4

TERMINOLOGY AND DEFINITIONS
There are several different forms of dietary sugars,
and the terminology used to describe them can be a
source of confusion for researchers, policy makers,
and consumers. Commonly used terms are described
below.

Sugar
Although commonly used more broadly, the US Federal
Drug Administration defines the term sugar as a sweet,
crystalline substance, C12H22O11, obtained chiefly from the juice of the sugarcane and the sugar beet.6
Total Sugars
The term total sugars is used conventionally to describe the monosaccharides glucose, galactose, and fructose,
as well as the disaccharides sucrose, lactose, maltose, and trehalose.7 Total sugars include all sugars in a food or beverage from any source, including those naturally
occurring (such as fructose in fruit and lactose in milk) and those added to foods.6
Added Sugars
Added sugars, as defined by the US Department of Agriculture, include all sugars used as ingredients in processed and prepared foods and sugars eaten separately or added to foods at the table.8 The term was first used in the 2000 US Dietary Guidelines for Americans to highlight foods and beverages that were higher in calories but lacked other important nutrients.9 Because fructose is the sweetest of the commonly consumed sugars, it
(or sugars that contain it) is frequently added to foods and beverages to increase their palatability. As a result, sucrose and high-fructose corn syrup, both of which are made up of glucose and fructose in approximately equal
amounts, are the most commonly added sugars in the
US food supply.

Naturally Occurring Sugars
Naturally occurring sugars include those that are an innate component of foods (eg, fructose in fruits and vegetables and lactose in milk and other dairy products).6 Extrinsic and Intrinsic Sugars
The terms extrinsic and intrinsic sugars originated
from the UK Department of Health. Intrinsic sugars
are defined as sugars that are present within the cell
walls of plants (eg, naturally occurring sugars) and
are always accompanied by other nutrients. Extrinsic
sugars are those not located within the cellular structure of a food and are found in fruit juice, honey, and syrups and added to processed foods. The term nonmilk extrinsic sugars is used to differentiate lactosecontaining extrinsic sugars from all others because Downloaded from http://ahajournals.org by on June 5, 2024

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CLINICAL STATEMENTS

AND GUIDELINES
the metabolic response for the 2 types of sugars differs substantially.10 Free Sugars
Free sugars is a term used by the World Health Organization that refers to all monosaccharides and disaccharides added to foods by the manufacturer, cook, and consumer (eg, added sugars) plus sugars naturally
present in honey, syrups, and fruit juices11 (eg, nonmilk extrinsic sugars).

CHALLENGES WITH STUDYING SUGARS

IN THE DIET
Nutrition studies are inherently challenging because humans have complex activities, diets, and metabolism. In Table 1. Added Sugars Intake by Food and Beverages Sources Among US Children and Adolescents, NHANES 2009 to 2012
Age, y
All (n=6412) 2–5 (n=1695) 6–11 (n=2300) 12–19 (n=2417)
Mean 95% CI Mean 95% CI Mean 95% CI Mean 95% CI
Total added sugars intake
Added sugars, % energy 16.1 15.6–16.6 13.5 13.1–13.8 16.4 15.9–16.8 17.2 16.3–18.1 Added sugars, g 80.0 77.2–82.7 53.3 51.2–55.3 78.7 76.6–80.8 93.9 89.1–98.8 Added sugars, teaspoon 19.0 18.4–19.7 12.7 12.2–13.2 18.7 18.2–19.2 22.4 21.2–23.5 SSBs, % energy 7.9 7.6–8.3 5.2 4.7–5.6 7.3 6.9–7.6 9.8 9.1–10.5 Added sugars by food source, g
Sweets 43.0 40.5–45.5 21.2 19.2–23.2 37.0 34.9–39.1 58.1 53.5–62.7 Sodas, regular 17.0 15.3–18.8 4.1 3.4–4.8 12.1 10.6–13.7 26.9 23.7–30.2 Fruit-flavored and sports drinks 12.9 12.1–14.6 10.0 8.5–11.4 12.7 11.5–13.9 14.4 12.3–16.5 Other beverages 0.3 0.2–0.4 0.1 0.0–0.2 0.3 0.1–0.6 0.3 0.2–0.5 Sugars and syrups 3.3 2.6–4.0 2.6 1.5–3.6 3.4 2.8–4.0 3.6 2.3–4.9 Candy and gum 5.0 4.2–5.7 3.6 3.1–4.1 5.7 4.6–6.7 5.1 3.9–6.4 Coffee and tea 4.0 3.1–4.9 0.9 0.6–1.1 2.8 1.8–3.9 6.4 4.6–8.2 Alcohol-containing drinks <0.1 <0.1–<0.1 0.0 0.0–0.0 0.0 0.0–0.0 0.1 0.0–0.2 Energy drinks 0.5 0.1–1.0 0.0 0.0–0.0 <0.1 <0.1–<0.1 1.2 0.2–2.2 Grains 20.0 19.2–20.7 15.8 14.9–16.7 22.4 20.9–23.9 20.2 18.7–21.7 Cakes and cookies 10.1 9.6–10.7 8.0 7.3–8.6 11.5 10.4–12.7 10.2 9.1–11.2 RTE cereals 4.4 4.0–4.8 3.7 3.2–4.2 4.8 4.2–5.5 4.4 3.6–5.1 Breads and muffins 3.2 2.9–3.5 2.3 1.8–2.9 3.4 2.9–3.9 3.4 3.0–3.9 Other grains 2.3 2.0–2.5 1.7 1.4–2.1 2.6 2.3–3.0 2.2 1.9–2.6 Dairy products 10.2 9.3–11.0 10.5 9.7–11.4 12.3 10.9–13.7 8.5 7.3–9.6 Dairy desserts 4.0 3.3–4.6 2.7 2.0–3.5 4.8 3.6–6.1 4.0 3.3–4.7 Sweetened milk 4.3 3.7–4.8 4.6 3.6–5.5 5.4 4.7–6.1 3.3 2.3–4.2 Yogurt 1.3 1.1–1.6 2.5 1.9–3.1 1.5 1.1–1.9 0.7 0.3–1.0
Other dairy 0.6 0.4–0.7 0.8 0.5–1.0 0.5 0.3–0.7 0.5 0.3–0.7 Fruits and vegetables 1.9 1.7–2.1 1.8 1.5–2.1 2.3 1.9–2.7 1.7 1.4–2.1 100% Fruit juices 0.0 0.0–0.0 0.0 0.0–0.0 0.0 0.0–0.0 0.0 0.0–0.0 Other fruits and vegetables 1.9 1.7–2.1 1.8 1.5–2.1 2.3 1.9–2.7 1.7 1.4–2.1 Meats, beans, eggs 1.9 1.7–2.2 1.3 1.0–1.7 1.7 1.4–1.9 2.4 2.0–2.9 Oil <0.1 <0.1–<0.1 <0.1 <0.1–<0.1 <0.1 <0.1–<0.1 <0.1 <0.1–<0.1 CI indicates confidence interval; NHANES, National Health and Nutrition Examination Survey; % energy, % total energy intake; RTE, ready to eat; and SSB, sugar-sweetened beverage.

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e1020 May 9, 2017 Circulation. 2017;135:e1017–e1034. DOI: 10.1161/CIR.0000000000000439 attempts to study a single nutrient such as sugar, it is impossible to isolate its effects completely, especially with the known limitations in self-reported diet data from children/parents and the short duration feasible with feeding studies. For example, adding sugars to a diet may result in the intake of excess calories. Some have proposed
that studies should be adjusted for these effects. However, adjustment does not mirror free-living people who do not typically adjust their diet or activity level to keep total calories at a set level. In fact, the most telling studies of the health effect of sugars are probably those in the real world. In our approach, we attempted to synthesize the
body of literature under each topic, including articles that reflect real-world effects of sugar and those that attempt to discern biological effects of isolated added sugars
administration while focusing on the goal of making highquality recommendations for practice and policy.

CURRENT INTAKE GUIDELINES
In 2005, sample diets for children from the Food Guide
Pyramid, which translated the Dietary Guidelines for
Table 2. Applying Classification of Recommendations and Level of Evidence A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Although randomized trials are unavailable, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.
*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as sex, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. †For comparative effectiveness recommendations (Class I and IIa; Level of Evidence A and B only), studies that support the use of comparator verbs should involve direct comparisons of the treatments or strategies being evaluated.

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CLINICAL STATEMENTS

AND GUIDELINES
Americans recommendations into food group–based advice for a healthy diet, suggested a limit ranging from 6% to 10% of total calorie intake as discretionary calories depending on a child’s age, sex, and level of physical activity. Discretionary calories are those available for consumption as added sugars and solid fats once a child’s daily nutrient requirements are met. In the same year,
this recommendation was supported by the American
Heart Association (AHA) in collaboration with the American Academy of Pediatrics, which also specified that “sweetened beverages and naturally sweet beverages,
such as fruit juice, should be limited to 4 to 6 ounces per day for children 1 to 6 years old and to 8 to 12 ounces per day for children 7 to 18 years old.”12
According to the 2010 Dietary Guidelines for Americans, reducing the consumption of added sugars would lower the energy content of the diet without compromising its nutrient adequacy.13 The guidelines suggested that this strategy could play an important role in reducing the high prevalence of obesity in the United States. The guidelines advised that sweetened foods and beverages
be replaced with those that have no added sugars or are low in added sugars. For example, the guidelines advise consumers to “drink water instead of sugary drinks.” Also in 2010, the AHA advised that, to achieve and maintain
healthy weights and to decrease cardiovascular risk while meeting essential nutritional needs, adults reduce their intake of added sugars.14 The AHA recommended an upper limit of intake of added sugars at 100 cal/d or 6 teaspoons for most American women and 150 cal/d or 9
teaspoons for most American men. The AHA recommendation focused on all added sugars without singling out any particular types such as high-fructose corn syrup.14 The 2015 Dietary Guidelines Advisory Committee released a scientific report in early 2015 recommending that added sugars be limited.15 The report pointed out that in a healthy meal pattern, after food group and nutrient recommendations are met, only a limited number of calories are available to be consumed as added sugars. Specifically, only 3% to 9% of calories would be available from added sugars for all patterns, and within the most appropriate patterns (1600–2400 cal), the range is 4% to 6% of calories from added sugars (or 4.5–9.4 teaspoons). The expert
committee concluded that strong and consistent evidence shows that intake of added sugars is associated with excess body weight compatible with a recommendation to keep added sugars intake <10% of total energy intake.

Since 2003, the World Health Organization has recommended that the intake of free sugars be limited to <10% of total daily energy intake.11 Guidelines released by the World Health Organization in 2015 advised that people
should reduce the amount of free sugars to <10% of
their daily energy intake.16 The World Health Organization further advised that a reduction to <5% of total energy intake per day would have additional benefits in reducing the risk of noncommunicable diseases (specifically excess weight gain and dental caries) in adults and children.16 Five percent of total energy intake is equivalent to ≈25 g (≈6 teaspoons or ≈100 kcal) of sugar per day for
an adult with a healthy body mass index (BMI).

CURRENT INTAKE LEVELS AND LEADING

SOURCES
We used publically available data from the most recent
cycles of the NHANES (2009–2012) to estimate current
levels of added sugars intake.17 These estimates may
be conservatively low because it is well established that self-reported dietary assessments underreport.18,19 Our analysis demonstrates that US children 2 to 19 years of age consume an average of 80 g added sugar daily (Table 1). Absolute intake is higher among boys than girls (87 versus 73 g), but there were no differences when
intake was assessed in relation to total energy intake
(16.1% for both). Added sugars intake increases with
age (Figure). Intake of free sugars, the combination of added sugars and sugars that occur naturally in honey,
syrups, and juices, is 91 g and 18.5% total energy.

Foods and beverages each contribute half of the
added sugars in children’s diets, 40 g each. The top
contributors to added sugars intake include soda, fruitflavored and sports drinks, and cakes and cookies. The contribution of added sugars to total energy intake is
summarized by food or beverage source in Table 1.

Table 3 illustrates sugars intake in teaspoons by sex
and age group.20 Previous research has suggested that
most added sugars are consumed at home rather than
away from home.21
SUGARS AND CVD RISK: BIOLOGICAL

MECHANISMS
An ongoing debate exists as to whether fructose and
glucose are similar in effect given that they are calorically matched but have markedly different metabolic fates in the human body. After consumption, digestion,
and absorption, both fructose and glucose are absorbed
into the portal circulation and taken up into the liver.22 The liver has a major role in controlling the amount of glucose that reaches peripheral tissues after a meal. Increased glucose in the portal blood stimulates insulin secretion, leading to increased uptake of glucose into
muscle and adipose, increased synthesis of glycogen,
increased fatty acid synthesis in the adipose, increased amino acid uptake, and induction of lipoprotein lipase
into muscle and adipose.22 Fructose does not stimulate
secretion of insulin to the same extent and is absorbed primarily into the liver where it stimulates de novo lipogenesis.23 The pathway of de novo lipogenesis produces saturated fatty acids, and although it is not a major pathway in lean individuals (contributing just 10% of fatty acDownloaded from http://ahajournals.org by on June 5, 2024

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e1022 May 9, 2017 Circulation. 2017;135:e1017–e1034. DOI: 10.1161/CIR.0000000000000439 ids in very-low-density lipoprotein triglyceride), in obese, insulin-resistant individuals, this pathway becomes important because carbohydrates may provide up to 50% of the saturated fatty acids in very-low-density lipoprotein triglyceride.24 In 2014, a review of these mechanisms included the postulation that because of this effect dietary sugars may be “as atherogenic as dietary saturated
fatty acids.”24 Whether the fructose or glucose causes
adverse effects may be academically debatable but is
less important from a clinical standpoint because most
food and beverage sources outside of research studies
include both sugars.

Genetics and How They Affect CVD Risk
A further challenge of understanding the role of sugars in CVD risk for children is the variability of response among individuals. This example of personalized response to a nutrient has confounded previous studies, but fortunately, recent investigations are revealing the underlying mechanisms. Genetics appear to have a profound influence on carbohydrate response. Davis et al25 demonstrated this in a study of the PNPLA3 (patatin-like phospholipase domain containing 3) gene, in which a
polymorphism of this gene modified the effect of dietary sugars on the presence of hepatic fat. Finally, but perhaps most obviously, the gut plays a critical role in nutrient absorption, response, and modification, and this is true for dietary sugars. At this point, little is known about the interaction between microbiome and added sugars
in humans; this is an area that needs study, particularly given the data demonstrating relationships between the
microbiome and CVD risk.26
Metabolic and Satiety Responses to Liquids
Versus Foods
The form in which added sugars are consumed also may
influence the metabolic effects. Sugar-sweetened beverages (SSBs) contribute a large number of calories to the American diet, and most are composed almost exclusively of just 2 ingredients, added sugars and water.

This makes them a good vehicle for testing the effect of added sugars with minimal risk of confounding by other
nutrients. As a result, nearly all clinical trials examining added sugars intake have been done with SSBs used as
the exposure. Insight into the effect of sugar-sweetened food consumption might be gained through studies of
foods high in total carbohydrates. Several short-term
studies have shown that carbohydrates consumed as
solids are more satiating then those consumed as liquids,27–30 and subsequent calorie balance appears to be compensated for by the additional calories, resulting in less body weight gain.27,31
DiMeglio and Mattes27 compared the effects of SSBs
versus isocaloric jelly beans in a crossover study among 15 adults and demonstrated an increase in body weight
Table 3. Added Sugars: Means, Percentiles, and Standard Errors of Usual Intake, 2007 to 2010 Age, y n*
Added Sugars, teaspoons†
Mean (SE)‡ 5% (SE) 10% (SE) 25% (SE) 50% (SE) 75% (SE) 90% (SE) 95% (SE) Boys 1–3 774 9.4 (0.31) 3.1 (0.17) 4.1 (0.19) 5.9 (0.24) 8.6 (0.29) 12.0 (0.39) 15.7 (0.51) 18.2 (0.62) 4–8 1001 15.7 (0.56) 6.5 (0.31) 7.9 (0.34) 10.9 (0.41) 14.8 (0.53) 19.6 (0.70) 24.6 (0.91) 28.1 (1.07) 9–13 850 21.5 (0.46) 5.9 (0.30) 8.0 (0.31) 12.5 (0.36) 19.3 (0.43) 27.9 (0.62) 37.9 (0.91) 44.8 (1.19) 14–18 808 24.6 (0.74) 7.3 (0.39) 9.7 (0.43) 14.7 (0.53) 22.2 (0.69) 31.9 (0.95) 42.8 (1.36) 50.2 (1.73) Girls 1–3 715 8.4 (0.27) 2.7 (0.17) 3.5 (0.20) 5.2 (0.23) 7.7 (0.28) 10.8 (0.33) 14.3 (0.41) 16.7 (0.45) 4–8 894 14.3 (0.37) 5.7 (0.27) 7.1 (0.30) 9.7 (0.33) 13.4 (0.37) 17.9 (0.44) 22.6 (0.57) 25.9 (0.68) 9–13 867 17.8 (0.44) 6.0 (0.29) 7.7 (0.31) 11.2 (0.35) 16.3 (0.42) 22.7 (0.55) 29.8 (0.77) 34.7 (0.96) 14–18 727 17.5 (0.54) 5.8 (0.34) 7.5 (0.37) 10.9 (0.43) 16.0 (0.52) 22.4 (0.65) 29.5 (0.90) 34.3 (1.10) *Number of people in sample.
†One teaspoon of added sugars equals the same amount of total sugars as 1 teaspoon (4 g) of table sugar (sucrose). ‡Standard errors (df=32).

Data derived from Usual Dietary Intakes: Food Intakes, US Population, 2007–2010.20 Figure. Mean daily kilocalories from added sugars
among children and adolescents 2 to 19 years of age,
by sex and age group: NHANES (National Health and
Nutrition Examination Survey), 2009 to 2012.

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over 4 weeks during the beverage condition but not with the jelly beans. Houchins et al32 performed a randomized, crossover study to compare the short- and longterm (8 weeks) effects of fruits and vegetables in solid versus beverage form on appetite and energy intake.

They found that hunger reduction was greater and subsequent food intake lower with solids compared with liquids in the short term, but there were no significant differences after 8 weeks. In a follow-up study, Houchins et al30 provided energy-matched liquid and solid forms
of fruits and vegetables to lean or overweight/obese
adults for 8 weeks each. Although incomplete dietary
compensation and weight gain occurred in both lean and
overweight/obese groups during the beverage condition,
results with the food condition were mixed. In the lean group, calorie compensation was precise, and there
was no weight gain; however, in the overweight/obese
group, compensation was poor, and there was significant weight gain.

Data are sparse on the impact of liquid versus solid
sugars consumption in children. In a 6-year longitudinal study of 8- to 10-year-old children, Olsen et al31 demonstrated a stronger association between liquid sucrose consumption and proxies of adiposity (BMI and waist
circumference) compared with solid sucrose consumption. Lee et al33 used data from a 10-year study with annual follow-up of adolescent girls to examine the association between added sugars intake and measures of adiposity. Before adjustment for total energy, each
additional teaspoon of added sugars consumed in either beverages or foods over the previous year was positively associated with change in waist circumference (0.18 mm/teaspoon; P<0.001) and change in BMI z score (0.002 units per teaspoon; P=0.003).

After adjustment for total energy, the association remained significant only for liquid added sugars and waist circumference (0.16 mm/teaspoon; P=0.02).

This supports the association between added sugars
consumed in either foods or beverages and weight gain
is mediated by total energy intake but also suggests
that liquid sugars may uniquely affect body fat distribution. These data support the reduction of all added sugars, but particularly SSBs, as a way to improve
long-term cardiovascular health.

CVD RISK OUTCOMES ASSOCIATED WITH

ADDED SUGARS INTAKE
Excess Weight Gain and Obesity
A preponderance of relevant literature supports a relationship between dietary sugars, specifically those found in SSBs, and increased adiposity in children.

As described below, these studies range from large
longitudinal studies to school-based, randomized, controlled trials with variable methods of dietary assessment and analyses (eg, not all adjust for total energy intake). Although evidence from cross-sectional studies has been mixed, many of these studies support a positive association between added sugar intakes and
adiposity.34–49
Higher intakes of SSBs have been associated with increased obesity risk among children of all ages. A small amount of literature has examined the consumption of
SSBs in infants and very young children. Early introduction of SSBs (before 12 months of age) has been evaluated and found to be associated with obesity at 6 years of age.50 In toddlers consuming no SSBs compared with
those consuming ≥2 SSBs per day, consuming no SSBs
was protective against obesity.51
In the preschool-aged group (2–5 years), 3 longitudinal studies52–54 and 1 retrospective study55 concluded that a high SSB intake was associated with a higher BMI z score,52 obesity at 5 to 7 years of age,53 and risk of being overweight.54 High intake of SSBs in preschoolers who were diagnosed as overweight or obese was associated with remaining overweight or obese 1 year later.50 In children 5 to 12 years of age, soda intake56 and SSB intake have been linked to increased BMI values and risk of being overweight or obese. A similar relationship was also found in adolescents; a higher intake of SSBs was
associated with a higher BMI,57,58 excess weight gain,59 and increased adiposity and weight status.60 Other studies have found no association with weight gain or adiposity in all age groups specifically when adjusted for total energy.34,37–39,41,45,61–66 A few studies have shown mixed results in which SSBs were associated with BMI
increases in their sample in girls66 or boys39 but not both.

The association between SSBs and various adiposity
outcomes has been more consistent. Higher SSB intake
has been linked specifically to higher skin-fold thickness,63 waist circumference,33,40 and excess body fat44 in children and adolescents, as well as a decrease in fat accumulation, when SSBs were replaced with a noncaloric beverage.67 Timing of SSB exposure may influence effects. For example, in the previously mentioned longitudinal study, SSB intake during infancy (<12 months of age) was associated with obesity at 6 years of age.50
Studies evaluating added and total sugars have been
less consistent in their findings, possibly as a result in part of methodological issues. High levels of added sugars intake at 2 years of age have been linked to BMI z scores at 7 years of age,68 but this finding has not
been consistent. In a cross-sectional study, added sugars did not significantly change BMI z scores in 8- to 18-year-olds.44 Total dietary sugars intake was found not to be predictive of BMI in a cross-sectional study using NHANES data for 1- to 18-year-olds.49 However, studies that examined total sucrose consumption over time have found that a higher intake of sucrose is related to an increased BMI,48 BMI z score,31 and waist circumference31 in children. A similar increase in total fat mass has Downloaded from http://ahajournals.org by on June 5, 2024

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e1024 May 9, 2017 Circulation. 2017;135:e1017–e1034. DOI: 10.1161/CIR.0000000000000439 been reported in children and adolescents who have high intakes of total sugars,35 fructose,47 and juice.69
In summary, children and adolescents who have high
intakes of dietary sugars (specifically from SSBs and
added sugars) tend to have higher daily energy intakes
compared with similar populations with lower intakes of dietary sugars. Higher SSB and added sugars intake has
been strongly linked to excess weight gain and an increased risk of obesity. Importantly, the associations of added sugars intake and adverse outcomes in the longitudinal and cross-sectional studies may also be driven by other factors such as the home environment, a broader
unhealthy diet, and activity behaviors. Additionally, in randomized, controlled trials in which children and adolescents switched from SSBs to noncaloric beverages,67,70 reductions in weight were found, strengthening the likelihood that it is added sugars intake (at least in beverage form) that drives the causality of the findings.

Elevated Blood Pressure and Uric Acid Levels
An epidemiological link between sweeteners and hypertension has been suspected for many years, but distinguishing the effects from those of obesity has been challenging. Jalal and colleagues71 evaluated this question in the NHANES data from 2000 to 2003. A strength of
this data set, a survey of a representative sample of US adults and children, is the inclusion of both direct blood pressure measurement and dietary intake of fructose as
determined by dietary questionnaire. The major finding
was that there was a strong relationship between fructose intake and elevated systolic blood pressure that was independent of obesity.71 Nguyen and colleagues72
also found an independent relationship between sugary
soft drinks and hypertension in adolescents. A converse observation that improvement in blood pressure during
lifestyle modification was greatest with a greater reduction in dietary sweeteners was made in a large study of adults randomized to brief counseling on the DASH
(Dietary Approach to Stop Hypertension) Diet.73
Direct clinical trials of fructose intake provide further support for a role of dietary sweeteners in the development of hypertension. Perez-Pozo et al74 administered 200 g fructose per day to healthy overweight males. Over the 2-week study period, subjects had an average increase
of 7 mm Hg in systolic blood pressure and 6 mm Hg in
diastolic blood pressure. Brymora and colleagues75 performed the converse experiment. Twenty-eight subjects were placed on a very low fructose diet in which they reduced their average intake from 59 to 12 g/d. After 6 weeks, the subjects had an average decrease of 6 mm Hg
in both systolic and diastolic blood pressures.

The physiological link between fructose and increased
blood pressure is likely indirect, acting through uric acid as an intermediary.76–79 In adolescents, there is a close association between elevated serum uric acid and the onset of essential hypertension. The Moscow Children’s Hypertension Study found hyperuricemia (>8.0 mg/dL) in 9.5% of children with normal blood pressure, 49% of children with borderline hypertension, and 73% of children with
moderate and severe hypertension.80 The Hungarian Children’s Health Study followed up all 17 634 children born in Budapest in 1964 for >13 years and also identified hyperuricemia as a risk factor for hypertension.81 In a small study, Gruskin82 compared adolescents (13–18 years
of age) with essential hypertension with age-matched,
healthy control subjects with normal blood pressures. The hypertensive children had both elevated serum uric acid (mean >6.5 mg/dL) and higher peripheral renin activity.

In a racially diverse population referred for the evaluation of hypertension, Feig and Johnson83 observed that the
mean serum uric acid level was 3.6 mg/dL in children with white-coat hypertension or normal blood pressure and
significantly higher, 6.7 mg/dL, in children with primary hypertension. Results from 2 small, clinical trials suggest that uric acid contributes directly to the development of hypertension in adolescents.84,85 Serum uric acid reduction, whether by reduced production or increased clearance, significantly improved elevated blood pressure.

In summary, both epidemiological and clinical trial evidence suggests that excessive fructose intake results in increased blood pressure in children and young adults.

There are data that this effect can be mitigated by uratelowering therapy consistent with the hypothesis that the hypertensive effect of dietary sugars is mediated by the induction of hyperuricemia. Current evidence suggests
that added sugars are a source of excess fructose and
that reduction of fructose from added sugars is likely to decrease uric acid, possibly improving blood pressure
in children. However, further research on this topic is needed to test whether a reduction in added sugars results in improved blood pressure in children.

Dyslipidemia
The majority of studies that evaluated lipid markers in children and associations with sugars, sucrose, fructose, or SSBs were cross-sectional. Of these studies, 2 had
mixed findings of increased glucose or homeostasis model assessment–estimated insulin resistance (HOMA-IR) and
systolic blood pressure with increased SSBs but no association with high-density lipoprotein (HDL) and triglyceride levels.86,87 The remaining 9 cross-sectional studies demonstrated positive associations between increasing amounts of added sugars and higher triglyceride and/or lower HDL levels.40,88–95 As expected, low-density lipoprotein and/or total cholesterol was less related and/or inversely associated with added sugars consumption in some studies.86,94,95
One of the older studies, published in 1980, was
unique because it included children who consumed very
low amounts of sugar, which is rare in today’s culture.94 Morrison et al94 examined cross-sectional data from
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1669 school children (75% white and 24% black), including total sucrose obtained from 24-hour recalls and measured blood lipids. Plasma triglycerides were positively correlated and total cholesterol was negatively correlated with dietary sucrose; this association remained after adjustment for age, race, and sex. When children were
divided into low (1st–10th percentile) versus intermediate and high consumers of sucrose, after adjustment for demographics, triglycerides rose with higher sucrose, HDL fell, and total plasma cholesterol fell as sucrose intake increased. Notably, the average consumption of the low
group was very low, ranging from 8 to 24 g/d (3.5%–

6.8% of calories per day). The average consumption of
sucrose of the intermediate group was between 42 and
80 g/d (9%–10% of calories per day), and the consumption of the high consumers was up to 17% of total calories per day. For triglycerides, there was a significant difference between the intermediate and high groups.

Four longitudinal studies included lipids as an outcome. All longitudinal studies confirmed an association between increased SSBs, sucrose, or added sugars and
increased triglycerides plus lower HDL.57,96–98 The Lee et al98 study included 10-year follow-up of >2000 racially diverse children who were 9 and 10 years of age at baseline. In low consumers of added sugars (<10% of total calories) compared with higher consumers, there was a

0.26-mg/dL annual increase (improvement) in HDL levels
over the 10 years. This added up to a 2.2 mg/dL higher
HDL in the low consumers of added sugars.

There has been 1 intervention study in obese children
comparing usual diet with a fructose-free study-provided diet. After 9 days of fructose-free diet, significant reductions were seen in triglycerides, low-density lipoprotein, blood pressure, and insulin sensitivity.99
In summary, although there are limited intervention
studies, the preponderance of evidence from the available cross-sectional and longitudinal studies weighs in favor of improved triglycerides and HDL in children with low consumption of added sugars. Although traditionally triglycerides and HDL have not been a primary focus
for decreasing CVD risk, newer data demonstrate that a
high ratio of triglycerides to HDL predicts smaller dense low-density lipoprotein, a strong cardiovascular risk factor.100 More studies are needed in this area, particularly focusing on the relationships of added sugars consumption in children and small dense low-density lipoprotein, HDL function, non–HDL cholesterol, and direct measurements of cardiovascular health such as carotid intimamedia thickness and brachial vasodilation.

Nonalcoholic Fatty Liver Disease
NAFLD has increased in the US population at an alarming rate, particularly among children.101 NAFLD is a disease of lipid metabolism in which excess triglycerides accumulates in hepatocytes in the setting of increased adiposity, hypertriglyceridemia, and increased free fatty acid flux to the liver caused by insulin resistance. The role of sugar intakes in NAFLD is only partially understood.

Nine articles were available that examined sugar intake and its correlation with hepatic steatosis in children.

Of the 4 cross-sectional studies, 2 studies reported an association between increased sugars intake and higher
liver fat25 or blood measurements of liver inflammation,102 1 study had conflicting findings,103 and 1 study did not show a relationship between total sugars or fructose
and hepatic steatosis.104 A large, longitudinal study that examined fructose consumption and NAFLD in 592 adolescents using ultrasound to identify hepatic steatosis found that energy-adjusted fructose intake at 14 years of age was independently associated with increased odds
of NAFLD at 17 years of age.105 Reduction in added
sugars has often been included as a part of a healthier lifestyle approach to treat NAFLD, and the combination
of higher fiber, increased vegetables, greater physical activity, and added sugars reduction has been shown to
be effective in reducing hepatic fat.106 However, the level of contribution of added sugars reduction to the positive findings in this type of intervention is unknown.

Few intervention studies that specifically targeted
added sugars and liver outcomes in children are available. A 4-week randomized, controlled, clinical trial compared type of sugar (fructose versus glucose) in a eucaloric beverage study in children with NAFLD and found that hepatic fat did not change when glucose was substituted for fructose, although insulin resistance and systemic inflammation improved.107 A small 6-month pilot study comparing education on a low-fat diet with education on a low-fructose diet found significant improvement in oxidized low-density lipoprotein and a strong trend of improvement in alanine amino transferase after a lowfructose diet educational intervention.103 In summary, although the cross-sectional data that
exist to date conflict, the 1 large longitudinal study available suggests a relationship between fructose consumption in children and hepatic fat. More research is needed, in particular because NAFLD does not occur in isolation and is almost always accompanied by 1 or all of the following: visceral obesity, hypertriglyceridemia, low HDL, high non–HDL cholesterol, and insulin resistance.108
Measuring outcomes of this clinical fatty liver syndrome after added sugars reduction may be a better marker of
improvement compared with studying hepatic fat or inflammation levels alone. Important research gaps in this area are the lack of longitudinal and randomized studies testing sugar reduction or substitution as a treatment for NAFLD in children, the lack of information on dose effect of added sugars on NAFLD or the associated CVD risk
factors, and the role of early sugars exposure on NAFLD.

These specific areas of knowledge are critical for guiding future practice and public health recommendations.

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Insulin Resistance and Diabetes Mellitus
The effects of added sugars on insulin sensitivity have been measured as primary or secondary outcomes in a
number of pediatric studies. A 2-year longitudinal study by Wang et al87 studied the associations between SSBs
and their effect on glucose-insulin homeostasis among
youth. The population included children between 8 and
10 years of age with at least 1 obese biological parent. Participants were classified as normal weight, overweight, or obese. Adipose measures, fasting glucose, fasting insulin, HOMA-IR, and the Matsuda insulin sensitivity index were measured. The data showed that a higher consumption (10 g/d) of added sugars from liquid sources was associated with 0.04-mmol/L higher fasting glucose, 2.3-mmol/L higher fasting insulin, a 0.1-unit higher HOMA-IR, and a 0.4-unit lower Matsuda insulin sensitivity index in all participants. These observed increases were statistically significant in children who were classified as overweight/obese but not among the normal-weight children. A cross-sectional study by Welsh et al95 of 2157 US adolescents in NHANES between 1999 and 2004
also showed a positive correlation between added sugars and HOMA-IR among overweight adolescents but not among those with normal weight.

Heden et al109 showed that moderate amounts of fructose- or glucose-sweetened beverages for 2 weeks did not differentially alter metabolic health in male and female adolescents when the 2 beverages were compared. The
study was a counterbalanced, single-blind study with 40 male and female adolescents but was limited by its short duration. Contrary to this study, Jin et al107 demonstrated in a slightly longer 4-week double-blind, randomized, controlled intervention study among Hispanic adolescents who were overweight with NAFLD that fructose beverage
consumption increased insulin, HOMA-IR, and adipose insulin resistance, whereas glucose beverage consumption was associated with lower insulin and HOMA-IR.

In summary, studies in this area are inconclusive.

To date, added sugars appear to have a relationship
with insulin resistance in children who are overweight, but this finding was not demonstrated in normal-weight
children.

EVIDENCE OF DOSE RESPONSE TO ADDED

SUGARS INTAKE
In our literature review, we found no studies directly testing what dose of added sugars in the diet of children would have no harmful effect on CVD risk. The
following is a summary of the results of studies from
each section above that indicate a level above which an increase in ≥1 cardiovascular risk factors was observed.

Cross-Sectional Studies
• Children consuming 3.5% to 6.8% of calories
as sucrose (the lowest consumption group) had
lower triglycerides and higher HDL than higher
consumers.94
• Children consuming no SSBs compared with those
consuming an average of 11.8 oz/d had lower
C-reactive protein, smaller waist circumference,
and higher HDL cholesterol.40
• Each additional SSB equivalent (≈1 cup or 8 oz)
consumed by children daily was associated with
a 5% increase in HOMA-IR, a 0.16-mm increase
in systolic blood pressure, a 0.47-cm increase in
waist circumference, a 0.90-percentile increase in
BMI for age, and a 0.48-mg/dL decrease in HDL
concentrations. The low consumers in this analysis
consumed a mean of 0.1 oz of SSBs per day.91
• Adolescents who consumed >10% of their total
energy as added sugars had lower HDL levels,
higher triglycerides, and higher low-density lipoprotein cholesterol levels than those who consumed less. Overweight or obese adolescents had higher
insulin resistance (as assessed with HOMA-IR).95
Prospective Cohort
• Adolescents consuming <10% of their total calories as added sugars had higher HDL cholesterol levels than those consuming more.98
• Children who consumed ≈10% of calories from
sucrose had a poorer diet quality and significantly
decreased height compared with lower consumers.48
• Infants who drank ≥3 servings of SSBs per week
had twice the odds of obesity at 6 years of age.50
• Annual changes in BMI z score and waist circumference among girls increased significantly with each additional teaspoon of added sugar.98
Experimental Studies
• In a randomized, controlled trial in school children, 1 SSB daily contributed an additional 104 cal
from added sugars (≈5% of a 2000-cal diet) and
increased body weight compared with a noncaloric
beverage daily.67
Thus, there is consistent evidence that cardiovascular
risk increases as added sugars consumption increases.

Very low consumption (0.1 oz of SSBs per day) is associated with lower CVD risk indicators. The “sweet spot” at which level of consumption added sugars could be
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enjoyed but without an adverse cardiovascular health effect is currently unknown.

DIET QUALITY AND ADDED SUGARS INTAKE
Decreased Diet Quality
Few studies have reported variations in nutrient adequacy (ie, decreased diet quality) based on intakes of added sugars; however, a study that examined this variation
suggested displacement of micronutrients with increasing amounts of sugars intake.110 Results from 10 years of follow-up in the National Growth and Health Study
reported low intakes of vitamins A, D, and E, calcium,
and potassium among adolescent girls across all 3 age
ranges (9–13, 14–18, and 19–20 years).111 These adolescents consumed >40% of total energy (>750 kcal/d) from solid fats and added sugars compared with the recommended limits ranging from 120 kcal/d for sedentary girls to 160 kcal/d for moderately active girls.

Diet quality may also be affected by total sugars intake and sources of sugars intakes. Frary and colleagues112
reported added sugars data in children and adolescents
from the 1994 to 1996 and 1998 Continuing Survey of
Food Intakes by Individuals database (US Department of
Agriculture). Whereas intake of presweetened dairy foods (ie, flavored milk or yogurts), beverages, and fortified cereals favorably affected levels of micronutrients, SSBs, sugars and sweets, and sweetened grains adversely affected diet quality. An Australian cross-sectional study of children 2 to 16 years of age based on two 24-hour recalls examined high glycemic carbohydrates, not sugars, and found that children who had a higher glycemic index of carbohydrates were more likely to fail to meet certain recommended nutrients, including calcium, and iodine.113 A longitudinal study of Finnish children that collected dietary information annually from infancy to 9 years of age found that the highest consumers of sucrose tended to
receive less vitamin E, niacin, calcium, iron, zinc, and dietary fiber compared with average and low consumers of sucrose.49 The lowest consumers of sucrose also consumed more grains, vegetables, and dairy products,49 thus supporting the idea that children who consume
added sugars in high levels are consuming fewer of the
micronutrients that are important for health.

A cross-sectional analysis of data from 2005 to 2008
NHANES reported that dietary sodium intake among US
children and adolescents 2 to 18 years of age was positively associated with SSB consumption.114 The average dietary sodium intake was 3056 mg/d, well in excess of
the recommended 2300 mg/d. The authors predicted
that with reductions in sodium intake, SSB intake and
thus calories from sugars intake would decrease. Among
those who consumed SSBs, each additional 390 mg of
sodium per day was associated with an increase of 32
g of SSBs per day.

Another potential consequence of higher sugars intake, especially in liquid form (eg, SSBs), is increased total energy intake that is not compensated for by reduced energy intake during meals.115 Sugary beverages were found to conflict in flavor with vegetables, thereby suggesting that “combo meals” that include SSBs are
typically not served with vegetables, whereas water or
milk is better accepted. Reduction of SSBs could decrease energy intake in children, as demonstrated in a study by Briefel et al.116 Briefel and colleagues used diet modeling and reported that switching from SSBs and flavored milks to unflavored low-fat milk at meals and water between meals saved on average 205 kcal/d, an ≈10%
reduction in total energy intake.

Increased Diet Quality
Empty calories in children’s diets should be limited to the amount that fits their energy and nutrient needs. The American Academy of Pediatrics Council on School Health and Committee on Nutrition advises using the minimal amount of added sugars necessary to promote the palatability, enjoyment, and consumption of nutrient-rich food items.117 Thus, it is important to be judicious when including added sugars in children’s diets. SSBs, sweets, and sweetened grains are more likely to have a negative impact on diet quality, whereas sweetened dairy products and presweetened cereals may have a positive impact.112 Examples of foods that may have a positive impact include sweetened dairy products such as low-fat or fat-free flavored milk, sweetened yogurt, and high-fiber breakfast cereals. Fatfree flavored milk intake is associated with higher intakes of shortfall nutrients such as calcium and potassium and is not associated with adverse effects on BMI measures.118 Furthermore, lower-calorie low-fat or fat-free milk with reduced added sugars appears to be acceptable to schoolaged children.119,120 Consuming ready-to-eat cereal at breakfast was associated with improved weight and nutrient adequacy in black children.121 However, compared with low-sugar cereals, high-sugar cereals increase children’s total sugar consumption and reduce the overall nutritional quality of their breakfast.122 From these studies, it is apparent that when children consume added sugars, it is better if the sugars are in foods and beverages that enhance, not diminish, the nutrient quality of the diet.

EARLY INTRODUCTION OF ADDED SUGARS
Children have a strong preference for a sweet taste, and early introduction of added sugars in the diet of infants and toddlers may promote sweet taste preference123 or may
reflect other factors in the feeding environment. (Early introduction of SSBs [before 12 months of age] is associated with an increased likelihood of consuming SSBs ≥1 time/ day at age 6 years.53) Recent research demonstrating the use of sucrose and glucose, which are sweeter than lacDownloaded from http://ahajournals.org by on June 5, 2024

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e1028 May 9, 2017 Circulation. 2017;135:e1017–e1034. DOI: 10.1161/CIR.0000000000000439 tose (the sugar found in breast milk), in infant formulas124 highlights the need for research in this area. We found no studies evaluating added sugars and infant formulas. Given the importance of this early period on growth and future obesity and metabolic risk, this is a critical research need.

ALTERNATIVES TO ADDED SUGARS
As part of this scientific statement, a review of the literature on nonnutritive sweeteners (NNSs; noncaloric artificial sweeteners) in children was performed because NNSs are often considered a tool to replace added
sugars to help lower energy intake. The key words nonnutritive sweeteners, artificial sweeteners, noncaloric sweeteners, and children were searched, with few relevant articles identified.125 This highlights a major gap in information that has also been noted in the adult literature.126,127 NNS-flavored beverages have been used as comparison groups in several pediatric trials of
SSBs.67,70 However, the studies were not designed to
examine the effects of NNSs and did not include a water comparison group.

Currently, consumption of NNSs is low in children, although it has increased over time. The AHA’s position on NNSs for adults is that, when used judiciously, NNSs substituted for added sugars in foods and beverages
could help people reduce their calorie intake to reach and maintain a healthy body weight, as long as the substitution does not lead to consuming additional calories as compensation.127 The American Academy of Pediatrics
concluded that data on NNSs are scarce in terms of the
long-term benefits for weight management in children
and adolescents or the consequences of long-term consumption.117 Because of the lack of research in children, a recommendation either for or against the routine use of NNSs in the diets of children cannot be made at this time.

RESEARCH GAPS
As discussed above, important gaps exist in the knowledge of sugars in children. Longitudinal studies, intervention studies, and randomized, controlled trials are urgently needed to provide high-quality data for policy decisions. Specific remaining questions that are research priorities include the following:
• Is there a threshold of added sugars below which there are no negative effects on cardiovascular health?
• Is there a direct linear relationship between increasing cardiovascular risk outcomes and added sugars intake? For example, is 1% better than 5%, which is
better than 10%? Does this change by age?
• Are the risks associated with added sugars consumption lower if the sugars are consumed in foods instead of in beverages?
• Does routine use of NNSs have adverse metabolic
effects in children?
• Can the food industry move to gradually lower the
amount of sugars added to foods, and if so, what
is the expected outcome?
• Does sugar from 100% juice have biological and
cardiovascular health effects in children similar to
those of added sugars from SSBs?

COMMITTEE RECOMMENDATIONS
On the basis of the existing literature and in combination with expert opinion, the following recommendations are made:

1. In randomized, controlled trials in which children
and adolescents switch from SSBs to noncaloric
beverages, reductions in weight were found,
strengthening the likelihood that it is added sugars
intake (at least in beverage form) that drives the
causality of the findings. Therefore, it is recommended that children and adolescents limit their intake of SSBs to 1 or fewer 8-oz beverages per
week (Class I; Level of Evidence A).

2. In the absence of dose-assessment studies, we
can only extrapolate from observational studies.

On the basis of the studies showing an association between decreased CVD risk factors and a low consumption of added sugars and the high potential benefit-to-risk ratio, it is reasonable to recommend that children and adolescents consume ≤25 g (100 cal or ≈6 teaspoons) of added sugars per
day (Class IIa; Level of Evidence C).

3. Because there is minimal room for nutrient-free
calories in the habitual diets of very young children,
added sugars should be avoided in the diet of children <2 years of age (Class III; Level of Evidence C).

CONCLUSIONS
Our comprehensive review of the available evidence
found that associations with increased CVD risk factors are present at levels far below US children’s current
added sugars consumption levels. Current evidence supports the associations of added sugars with increased energy intake, increased adiposity, increased central adiposity, and increased dyslipidemia, all of which are demonstrated CVD risk factors. Importantly, the introduction of added sugars during infancy appears to be particularly harmful and should be avoided. Although added sugars
can mostly likely be safely consumed in low amounts as
part of a healthy diet, little research has been done to establish a threshold between adverse effects and health, making this an important future research topic.

FOOTNOTES
The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a Downloaded from http://ahajournals.org by on June 5, 2024

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CLINICAL STATEMENTS

AND GUIDELINES
result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

This scientific statement was approved by the American
Heart Association Science Advisory and Coordinating Committee on February 22, 2016, and the American Heart Association Executive Committee on March 23, 2016. A copy of the document is available at http://professional.heart.org/statements by using either “Search for Guidelines & Statements” or the “Browse by Topic” area. To purchase additional reprints, call 843-216-2533 or e-mail [email protected].

The American Heart Association requests that this document be cited as follows: Vos MB, Kaar JL, Welsh JA, Van Horn LV, Feig DI, Anderson CAM, Patel MJ, Munos JC, Krebs NF, Xanthakos SA, Johnson RK; on behalf of the American Heart Association Nutrition Committee of the Council on Lifestyle and Cardiometabolic Health; Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Functional Genomics and Translational Biology; and Council on Hypertension. Added sugars and cardiovascular disease risk in children: a scientific statement from the American Heart Association. Circulation. 2017;135:e1017–e1034. doi: 10.1161/CIR.0000000000000439.

Expert peer review of AHA Scientific Statements is conducted by the AHA Office of Science Operations. For more on AHA statements and guidelines development, visit http://professional. heart.org/statements. Select the “Guidelines & Statements” drop-down menu, then click “Publication Development.”
Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association.

Instructions for obtaining permission are located at http://www. heart.org/HEARTORG/General/Copyright-Permission-Guidelines_ UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page.

Circulation is available at http://circ.ahajournals.org.

DISCLOSURES
Writing Group Disclosures
Writing Group
Member Employment
Research
Grant
Other
Research
Support
Speakers’
Bureau/
Honoraria
Expert
Witness
Ownership
Interest
Consultant/
Advisory
Board Other
Miriam B. Vos Emory University School
of Medicine
None None None None None None None
Cheryl A.M.

Anderson
University of California San
Diego School of Medicine
None None None None None None None
Daniel I. Feig University of Alabama
at Birmingham
None None None None None None None
Rachel K.

Johnson
University of Vermont None None None None None Milk Processor Education Program*
None
Jill L. Kaar University of Colorado
Anshutz Medical Campus
None None None None None None None
Nancy F. Krebs University of Colorado None None None None None None None Jessica Cruz
Munos
Emory University
Department of Pediatrics
None None None None None None None
Mahesh J. Patel Merck Research
Laboratories
None None None None None None None
Linda V. Van Horn Northwestern University None None None None None None None Jean A. Welsh Emory University None None None None None Sugar Board/ presentation on trends
in added sugar intake
among toddlers*
None
Stavra A.

Xanthakos
Cincinnati Children’s
Hospital Medical Center
None None None None None None None
This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be “significant” if (a) the person receives $10 000 or more during any 12-month period, or 5% or more of the person’s gross income; or (b) the person owns 5% or more of the voting stock or share of the entity, or owns $10 000 or more of the fair market value of the entity. A relationship is considered to be “modest” if it is less than “significant” under the preceding definition. *Modest.

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†Significant.

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CLINICAL STATEMENTS

AND GUIDELINES

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95. Welsh JA, Sharma A, Cunningham SA, Vos MB. Consumption of added sugars and indicators of cardiovascular disease risk among US adolescents. Circulation. 2011;123:249–257. doi:

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96. Williams CL, Strobino BA. Childhood diet, overweight, and CVD risk factors: the Healthy Start project. Prev Cardiol. 2008;11:11–20.

97. Ruottinen S, Rönnemaa T, Niinikoski H, Lagström H, Saarinen M, Pahkala K, Kaitosaari T, Viikari J, Simell O. Carbohydrate intake, serum lipids and apolipoprotein E phenotype show association in children. Acta Paediatr. 2009;98:1667–1673. doi:

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98. Lee AK, Binongo JN, Chowdhury R, Stein AD, Gazmararian JA, Vos MB, Welsh JA. Consumption of less than 10% of total energy from added sugars is associated with increasing HDL in females during adolescence: a longitudinal analysis. J Am Heart Assoc. 2014;3:e000615. doi: 10.1161/JAHA.113.000615.

99. Lustig RH, Mulligan K, Noworolski SM, Tai VW, Wen MJ, ErkinCakmak A, Gugliucci A, Schwarz JM. Isocaloric fructose restriction and metabolic improvement in children with obesity and metabolic syndrome. Obesity (Silver Spring). 2016;24:453–460. doi: 10.1002/oby.21371.
100. Burns SF, Lee SJ, Arslanian SA. Surrogate lipid markers for small dense low-density lipoprotein particles in overweight youth. J Pediatr. 2012;161:991–996. doi: 10.1016/j.jpeds.2012.06.013. 101. Welsh JA, Karpen S, Vos MB. Increasing prevalence of nonalcoholic fatty liver disease among United States adolescents, 1988–1994 to 2007–2010. J Peds. 2013;162:496–500.e1.
doi: 10.1016/j.jpeds.2012.08.043.
102. Mager DR, Patterson C, So S, Rogenstein CD, Wykes LJ, Roberts EA. Dietary and physical activity patterns in children with fatty liver. Eur J Clin Nutr. 2010;64:628–635. doi: 10.1038/ ejcn.2010.35.
103. Vos MB, Weber MB, Welsh J, Khatoon F, Jones DP, Whitington PF, McClain CJ. Fructose and oxidized low-density lipoprotein in pediatric nonalcoholic fatty liver disease: a pilot study. Arch Pediatr Adolesc Med. 2009;163:674–675. doi: 10.1001/
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104. Mollard RC, Sénéchal M, MacIntosh AC, Hay J, Wicklow BA, Wittmeier KD, Sellers EA, Dean HJ, Ryner L, Berard L, McGavock JM. Dietary determinants of hepatic steatosis and visceral adiposity in overweight and obese youth at risk of type 2 diabetes. Am J Clin Nutr. 2014;99:804–812. doi: 10.3945/ ajcn.113.079277.
105. OʼSullivan TA, Oddy WH, Bremner AP, Sherriff JL, Ayonrinde OT, Olynyk JK, Beilin LJ, Mori TA, Adams LA. Lower fructose intake may help protect against development of nonalcoholic fatty liver in adolescents with obesity. J Pediatr Gastroenterol Nutr. 2014;58:624–631. doi: 10.1097/MPG.0000000000000267.
106. Grønbæk H, Lange A, Birkebæk NH, Holland-Fischer P, Solvig J, Hørlyck A, Kristensen K, Rittig S, Vilstrup H. Effect of a 10- week weight loss camp on fatty liver disease and insulin sensitivity in obese Danish children. J Pediatr Gastroenterol Nutr. 2012;54:223–228. doi: 10.1097/MPG.0b013e31822cdedf.
107. Jin R, Welsh JA, Le NA, Holzberg J, Sharma P, Martin DR, Vos MB. Dietary fructose reduction improves markers of cardiovascular disease risk in Hispanic-American adolescents with NAFLD.

Nutrients. 2014;6:3187–3201. doi: 10.3390/nu6083187.
108. Jin R, Le NA, Liu S, Farkas Epperson M, Ziegler TR, Welsh JA, Jones DP, McClain CJ, Vos MB. Children with NAFLD are more sensitive to the adverse metabolic effects of fructose beverages than children without NAFLD. J Clin Endocrinol Metab. 2012;97:E1088–E1098. doi: 10.1210/jc.2012-1370.
109. Heden TD, Liu Y, Park YM, Nyhoff LM, Winn NC, Kanaley JA.

Moderate amounts of fructose- or glucose-sweetened beverages do not differentially alter metabolic health in male and female adolescents. Am J Clin Nutr. 2014;100:796–805. doi: 10.3945/ ajcn.113.081232.
110. Moore LL, Singer MR, Qureshi MM, Bradlee ML, Daniels SR. Food group intake and micronutrient adequacy in adolescent girls.

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111. Striegel-Moore RH, Thompson D, Affenito SG, Franko DL, Obarzanek E, Barton BA, Schreiber GB, Daniels SR, Schmidt M, Crawford PB. Correlates of beverage intake in adolescent girls: the National Heart, Lung, and Blood Institute Growth and Health Study. J Pediatr. 2006;148:183–187. doi: 10.1016/j. jpeds.2005.11.025.
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114. Grimes CA, Wright JD, Liu K, Nowson CA, Loria CM. Dietary sodium intake is associated with total fluid and sugar-sweetened beverage consumption in US children and adolescents aged 2-18 y: NHANES 2005-2008. Am J Clin Nutr. 2013;98:189–196. doi:

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115. Cornwell TB, McAlister AR. Contingent choice: exploring the relationship between sweetened beverages and vegetable consumption.

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118. Murphy MM, Douglass JS, Johnson RK, Spence LA. Drinking flavored or plain milk is positively associated with nutrient intake and is not associated with adverse effects on weight status in US children and adolescents. J Am Diet Assoc. 2008;108:631–639. doi: 10.1016/j.jada.2008.01.004.
119. Yon BA, Johnson RK. Elementary and middle school children’s acceptance of lower calorie flavored milk as measured by milk shipment and participation in the National School Lunch Program.

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41.134
NOSH
Large study on Berkeleyʼs soda tax }nds signi}-
cant drop in sugary beverage sales
The Public Health Institute and University of North Carolina study shows tax is doing “exactly what it is intended to do” says its lead author.

By Kate Darby Rauch
April 24, 2017, 2:30 p.m.

A new study concludes Berkeleyʼs soda tax is doing “exactly what it is intended to do,” says its lead author. Photo: Thomas Hawk A detailed analysis of Berkeley’s sugary beverage tax shows a near 10% drop in sales of sodas, energy drinks and other taxed beverages in the year after the tax started, according to a recent study by er
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6/5/24, 8:42 PM Large study on Berkeley’s soda tax finds significant drop in sugary beverage sales https://www.berkeleyside.org/2017/04/24/large-study-berkeleys-soda-tax-finds-significant-drop-sugary-beverage-sales 41.135 1/6 Read more about
Berkeley’s pioneering
soda tax.
researchers at the Oakland-based Public Health Institute and University of North Carolina.

This indicates the tax is doing exactly what it was intended to do, said Lynn Silver, a lead author of the study, which was published in PLOS Medicine this week. “The exciting news is that the tax seems to be working,” said Silver, a pediatrician who lives in Berkeley.

And in a surprise to Silver, the study also showed Berkeley sales of healthier drinks such as water and milk increased after the tax.

In addition, overall grocery sales didn’t decline even if people were buying less soda, so the tax hasn’t been detrimental to business owners — a frequent concern voiced by tax opponents.

And people’s grocery bills didn’t jump, another prediction of many tax foes. “It appears to be a home run on a public policy,” Silver said.

The three-part analysis looked at three studies conducted before and after the tax: 15.5 million scans of check-out data at three major Berkeley chain grocery stores; beverage pricing at 26 Berkeley stores, including large and small groceries, pharmacies and gas stations; and a telephone survey of 950 adult Berkeley residents.

Analysis included data from Bay Area control group stores outside of Berkeley, for comparisons. The names of stores involved in the research are confidential.

Pre-tax information was gathered before Jan. 1, 2015; post tax, between March 1, 2015 when the tax was implemented and Feb. 29, 2016.

Passed in 2014 by voters with overwhelming support, Berkeley’s soda tax, as it’s often called, imposes a penny per-fluid-ounce tax on a range of sugary beverages charged to distributors, not stores or customers.

Taxed drinks include soda, energy drinks, juices with added sugar, and sugary syrups added to coffee drinks.

Studyʼs key }ndings
The study findings included:

Sales (in ounces per transaction) of taxed drinks fell by 9.6% in Berkeley, while they rose by 6% in Bay Area stores without a tax.
in Bay
6/5/24, 8:42 PM Large study on Berkeley’s soda tax finds significant drop in sugary beverage sales https://www.berkeleyside.org/2017/04/24/large-study-berkeleys-soda-tax-finds-significant-drop-sugary-beverage-sales 41.136 2/6 Sales of non-taxed healthier drink options such as water, 100% juice and milk increased by 3.5%, with water increasing by 15.6%, untaxed fruit, vegetable, and tea drinks by 4.4%, and milk by 0.63% Overall beverage sales in Berkeley increased. “That makes it unlikely there would be a negative job impact,” Silver said.

Overall chain grocery revenues (store revenue per transaction) in the Bay area dropped slightly during the post tax study period, but Berkeley revenues declined by 18 cents less than non-Berkeley stores. (-$0.36 compared to $-0.54.) This same measure showed that average grocery bills paid by consumers did not go up.

Silver’s research found that the tax was passed on to consumers in higher prices in most, but not all stores.

In the 15.5 million scan supermarket chain study; about two-thirds of the tax charged to distributors was passed to shoppers; though it was fully passed on sodas and energy drinks. In the 26-store study, the tax was fully passed on in large and small chain supermarkets and chain gas stations; partially passed on in pharmacies, and not passed on in independent corner stores and gas stations.

Because the tax was phased in and didn’t affect independent stores until January 2016, compared to March 2015, this category of data is limited, Silver said. “Our study only captured the first two months of small stores; it’s possible they hadn’t adapted their pricing.” Research doesnʼt indicate much ʻborder shoppingʼ
When asked if she thinks Berkeley residents are stepping over the border to buy sodas from neighboring towns, Silver said maybe a little, but the research doesn’t indicate a major shift. She points to a few findings including the telephone survey, where 90% of people said they bought their beverages in Berkeley before the tax, and 94% after the tax, an insignificant difference.

She also noted that overall beverage sales increased in Berkeley during the study period. “People are unlikely to be increasing their beverage purchases in Berkeley and buying a lot outside of Berkeley,” she said.

But the study found a slight increase in sugary beverage purchases in the non-Berkeley control stores, “so some leakage is possible,” Silver said. Today, several neighboring towns have soda taxes including Albany, Oakland and San Francisco, which should curb “border shopping,” Silver said.

The study shows changes at grocery stores. But it will take time to document the health effects of Berkeley’s tax on health, Silver said.

Though she, and other health researchers supporting sugary beverage taxes, base their support on computer-modeled studies showing a significant link between lowering soda consumption and health 6/5/24, 8:42 PM Large study on Berkeley’s soda tax finds significant drop in sugary beverage sales https://www.berkeleyside.org/2017/04/24/large-study-berkeleys-soda-tax-finds-significant-drop-sugary-beverage-sales 41.137 3/6 benefits, she said.
“It will take more time to see those changes, but a number of researchers have modeled what we might expect to see,” Silver said.

A pro-soda tax demo outside Old City Hall in July 2014. Photo: Berkeley vs Big Soda American Beverage Association: Study shows tax is not impacting health A statement from the American Beverage Association (ABA), a trade group that actively campaigns against soda taxes, including Berkeley’s, said Silver’s study shows the tax isn’t impacting health. “This study acknowledges that taxes do not demonstrate a meaningful reduction in obesity rates,” the statement said. “A beverage tax that increases the price on certain beverages by more than 50% only yields a reduction of 6.4 calories per day.”
William Dermondy, vice president for policy at the association, pointed to a table in Silver’s study that estimated the mean caloric intake of taxed beverages dropped by 6.4 calories daily after the tax, based on the telephone survey, a number the study called not statistically significant. “That difference isn’t even measureable on a bathroom scale,” he said.
ven
6/5/24, 8:42 PM Large study on Berkeley’s soda tax finds significant drop in sugary beverage sales https://www.berkeleyside.org/2017/04/24/large-study-berkeleys-soda-tax-finds-significant-drop-sugary-beverage-sales 41.138 4/6 The association’s statement also said that Berkeley’s relative small size, high median income, and low baseline consumption “make it a challenging place to determine the true impact of a beverage tax.” Dermonday said: “We all want the same thing, better public heath, we just have an honest disagreement with some that taxes are going to achieve it. They’ve never been shown to do that; we don’t believe they will.”
In response, Silver said the beverage association’s statement is seriously misleading.

Her study never intended to look at obesity rates, she said. “This study in no way acknowledges such a finding. The soda tax did what it set out to do, which was to lower the sales of sugar-sweetened beverages and to increase consumption of healthier beverages. It is far too soon to assess the impact of the tax on obesity and diabetes rates.”
And the statement’s reference “a more than 50% increase” in prices is bogus, Silver said.

She also took issue with the association’s claim that a study of Berkeley’s tax can’t gauge impact. “The Berkeley findings demonstrate that when an informed population shifts to healthier beverages, overall beverage sales can stay the same or grow, keeping local businesses healthy too,” Silver said. “That’s exactly what we didn’t know when we set out to do the study, whether in a relatively prosperous town like Berkeley it would affect people’s choices, but it did,” Silver said. “It was a clear difference from the control communities.

The new study follows one conducted by UC Berkeley and released last summer which showed a 21% drop in the drinking of soda and other sugary beverages in Berkeley’s low-income neighborhoods.

Even with last year’s dip in soda sales, enough people bought sugary drinks to add $1.5 million to Berkeley’s general fund, earmarked for nutrition and obesity prevention.

Revenue to date is $3 million.

Indeed, if people in Berkeley spend less and less on sugary drinks, the sugar tax pot will also decrease. It’s the double-edged sword of a soda tax.
“The goal is to reduce consumption of sugar sweetened beverages. If no one is drinking sugar-sweetened beverages, that would be a victory for the city and for the community’s health,” said Matthai Chakko, city of Berkeley spokesman.
6/5/24, 8:42 PM Large study on Berkeley’s soda tax finds significant drop in sugary beverage sales https://www.berkeleyside.org/2017/04/24/large-study-berkeleys-soda-tax-finds-significant-drop-sugary-beverage-sales 41.139 5/6 14 comments
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6/5/24, 8:42 PM Large study on Berkeley’s soda tax finds significant drop in sugary beverage sales https://www.berkeleyside.org/2017/04/24/large-study-berkeleys-soda-tax-finds-significant-drop-sugary-beverage-sales 41.140 6/6 Too much added sugars increases your risk of type II diabetes Sugar & Type II Diabetes
FACT SHEET | Sugar & Type II Diabetes 1
HEALTHY FOOD AMERICA | FACT SHEET
healthyfoodamerica.org
HOW MUCH ADDED SUGARS* ARE WE CONSUMING?1
US adults consume 18 tsp per day = 40% too much
US children consume 19 tsp per day = 70% too much
Quick Facts About Type II Diabetes
• Diabetes is a chronic condition that prevents the body from properly using the hormone insulin that regulates blood sugar.6
• Diabetes can lead to kidney failure, blindness, heart attack, stroke, and nerve and blood vessel damage in the feet which can lead to foot infections and lower limb amputation.6 • 45.6 million Americans have diagnosed or undiagnosed diabetes. Black and Hispanic adults are twice as likely to have diabetes as white counterparts (21% versus 11%).7 • By 2050, 1 in every 3 adults could have diabetes in the US.8 The medical costs associated with diabetes were $245 billion in 2012.9
Learn more about what to do about added sugars and sugary drinks here:

Healthy Food America
Developed February 2017
Children and adults are eating and drinking added
sugars at well over the daily recommended amount.2
The result is increased risk for serious health
problems, like diabetes.
*Added sugars are sugars and syrups added to foods during preparation or processing, or at the table, and include cane and beet sugar, high fructose corn sweetener, glucose, dextrose, honey, and edible syrups.

Almost 2 out of 3 youth consume
sugary drinks every day
241 calories/day3
risk of type II
diabetes4
26%
the accumulation
of fat in the liver5
140%
1 out of 2 adults consume
sugary drinks every day
283 calories/day3
=
The accumulation of fat in
the liver and elsewhere in
the body directly contributes
to insulin resistance and
type II diabetes.

Drinking
sugary
drinks
regularly

41.141
FACT SHEET | Sugar & Type II Diabetes 2

REFERENCES
1 Powell ES, Smith-Taillie LP, Popkin BM. Added Sugars Intake Across the Distribution of US Children and Adult Consumers: 1977-2012. J Acad Nutr Diet. 2016;116(10):1543-50. 2 US Department of Health and Human Services and U.S. Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/. 10% or less of daily calories should come from added sugars.
3 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):180-8. Data are based on one 24-hour dietary recall. 4 Malik VS, Popkin BM, Bray GA, et al. Sugar- sweetened beverages and risk of metabolic syndrome and type 2 diabetes: a meta-analysis. Diabetes Care. 2010;33:2477–83. 5 Maersk M, Belza A, Stodkilde-Jorgensen H, et al. Sucrose-sweetened beverages increase fat storage in the liver, muscle, and visceral fat depot: a 6-mo randomized intervention study. Am J Clin Nutr. 2012;95(2):283-89.
6 Centers for Disease Control and Prevention. Diabetes: At A Glance 2016. https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm. Updated July 25, 2016.

Accessed January 3, 2016.
7 Prevalence of and Trends in Diabetes Among Adults in the United States, 1988-2012.

Menke A, Casagrande S, Geiss L, Cowie CC. JAMA. 2015;314(10):1021-9. 8 Centers for Disease Control and Prevention. Diabetes Report Card 2014. Atlanta, GA: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2015. 9 Yang W, Dall TM, Halder P, Gallo P, Kowal SL, Hogan PF. Economic costs of diabetes in the U.S. in 2012. Diabetes Care. 2013;36(4):1033-46.

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Too much added sugar increases your risk of tooth decay FACT SHEET | Sugar & Tooth Decay 1
HEALTHY FOOD AMERICA | FACT SHEET
healthyfoodamerica.org
HOW MUCH ADDED SUGARS* ARE WE CONSUMING?1
US adults consume 18 tsp per day = 40% too much
US children consume 19 tsp per day = 70% too much
Quick Facts About Tooth Decay
• Cavities are common throughout the lifespan and can lead to dental pain and tooth loss.6 Children who experience dental pain are more likely to miss school and can have difficulty learning.7
• One-third of children aged 2–8 years have cavities in their baby teeth. More Hispanic children (46%) and black children (44%) have cavities in their baby teeth compared to white children (31%).8
• One in five children aged 6–11 years have cavities in their permanent teeth.8 • Among adults aged 20–64 years, 91% have cavities.9
Learn more about what to do about added sugars and sugary drinks here:

Healthy Food America
Developed February 2017
Children and adults are eating and drinking added
sugars at well over the daily recommended amount.2
The result is increased risk for serious health
problems, like tooth decay.
*Added sugars are sugars and syrups added to foods during preparation or processing, or at the table, and include cane and beet sugar, high fructose corn sweetener, glucose, dextrose, honey, and edible syrups.

Almost 2 out of 3 youth consume
sugary drinks every day
241 calories/day3
Cavity-forming acids are produced when mouth bacteria metabolize sugars. risk of
tooth decay4
31%
chances of cavities at age 6
if consumed at least three
times a week in infancy 5
83%
1 out of 2 adults consume
sugary drinks every day
283 calories/day3
=
Sugar & Tooth Decay
Drinking
sugary
drinks
regularly

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FACT SHEET | Sugar & Tooth Decay 2

REFERENCES
1 Powell ES, Smith-Taillie LP, Popkin BM. Added Sugars Intake Across the Distribution of US Children and Adult Consumers: 1977-2012. J Acad Nutr Diet. 2016;116(10):1543-50. 2 US Department of Health and Human Services and US Department of Agriculture. 2015 – 2020 Dietary Guidelines for Americans. 8th Edition. December 2015. Available at http://health.gov/dietaryguidelines/2015/guidelines/. 10% or less of daily calories should come from added sugars.
3 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):180-8. Data are based on one 24-hour dietary recall. 4 Bernabé E, Vehkalahti MM, Sheiham A, Aromaa A, Suominen A. Sugar-sweetened beverages and dental caries in adults: A 4-year prospective study. J Dent. 2014;42(8):952-8. 5 Park S, Lin M, Onufrak S, Li R. Association of Sugar-Sweetened Beverage Intake during Infancy with Dental Caries in 6-year-olds. Clin Nutr Res. 2015;4(1): 9-17. 6 National Institutes of Health. Dental cavities. https://medlineplus.gov/ency/article/001055.htm.

Updated January, 5 2017. Accessed January 31, 2017.
7 Holt K, Barzel R. 2013. Oral Health and Learning: When Children’s Oral Health Suffers, So Does Their Ability to Learn (3rd ed.). Washington, DC: National Maternal and Child Oral Health Resource Center.
8 Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and sealant prevalence in children and adolescents in the United States, 2011-2012. NCHS Data Brief. 2015;(191):1-8. 9 Dye B, Thornton-Evans G, Li X, Iafolla T. Dental caries and tooth loss in adults in the United States, 2011-2012. NCHS Data Brief. 2015;(197):197.

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SCIENCE & MEDICINE
Berkeley sees a big drop in soda consumption after penny-perounce ‘soda tax’ After Berkeley instituted a penny-per-ounce tax on sugar-sweetened beverages, consumption of the high-calorie drinks fell by 21% in the city’s low-income neighborhoods. (Frederic J. Brown / AFP/Getty Images) By Karen Kaplan
Aug. 23, 2016 4:20 PM PT
Can Americans tax themselves out of their obesity crisis? A new analysis of Berkeley’s first-in-the-nation “soda tax” offers encouraging results about its power to change people’s dietary habits.

Five months after the city implemented its penny-per-ounce tax on all manner of sugarsweetened beverages, lower-income residents had reduced their consumption by 21%, 6/5/24, 5:56 PM Berkeley sees a big drop in soda consumption after penny-per-ounce ‘soda tax’ - Los Angeles Times https://www.latimes.com/science/sciencenow/la-sci-sn-soda-tax-works-20160823-snap-story.html 41.145 1/6 compared to the pre-tax days. Meanwhile, their counterparts in neighboring Oakland and San Francisco increased the amount of sugary drinks consumed by 4% during the same period, according to a study published Tuesday in the American Journal of Public Health.

Instead of swilling as much Coke, Gatorade, Red Bull and Hawaiian Punch, the Berkeley residents boosted their water consumption by 63%. In the neighboring cities, lowincome residents drank only 19% more water during the study period.

The results provide strong evidence that the sin taxes that helped steer consumers away from alcohol and tobacco products can also work on sugary drinks such as soda, said Dr.

Kristine Madsen, a public health researcher at UC Berkeley and senior author of the study.
“While Berkeley is just one small city, this is an important first step in identifying tools that can move the needle on population health,” Madsen said in a statement.

About two dozen states have considered excise taxes on sugar-sweetened beverages, as have cities such as Baltimore, Chicago, Philadelphia, San Francisco and Washington, D.C., according to the Rudd Center for Food Policy and Obesity at the University of Connecticut. But Berkeley was the first jurisdiction to pass one. The campaign in favor of Measure D was framed as “Berkeley vs. Big Soda,” and it passed in 2014 with 75% of the vote.

Unlike a sales tax, which shoppers see at the register, an excise tax gets incorporated into the price of an item. Three months after Measure D went into effect, 47% of the penny-per-ounce tax had been passed along to consumers in the form of higher prices for sugar-sweetened beverages, according to a previous study by some of the same researchers. For sodas in particular, 69% of the tax was incorporated into the price. 6/5/24, 5:56 PM Berkeley sees a big drop in soda consumption after penny-per-ounce ‘soda tax’ - Los Angeles Times https://www.latimes.com/science/sciencenow/la-sci-sn-soda-tax-works-20160823-snap-story.html 41.146 2/6 To see whether the tax would change anyone’s buying habits, Madsen and her colleagues from UC Berkeley and UC San Francisco sent interviewers to busy intersections in census tracts with large numbers of low-income and non-white residents. They focused on these groups because they are “more likely to consume [sugar-sweetened beverages] and suffer related health consequences,” such as obesity, diabetes and heart disease, the researchers wrote.

Interviewers asked residents in Berkeley, Oakland and San Francisco how often they drank beverages in five categories: full-calorie soda, sports drinks, energy drinks, fruit drinks and sweetened tea or coffee concoctions. The first set of interviews occurred at least eight months before the tax went into effect; the second set was completed five months after it was implemented. Nearly 3,000 people answered the questions in either English or Spanish.

ADVERTISEMENT
After controlling for the age, gender, race, ethnicity and education level of those who took the survey, researchers found that the drinking habits of Berkeley residents were starkly different from those of similar people in Oakland and San Francisco. 6/5/24, 5:56 PM Berkeley sees a big drop in soda consumption after penny-per-ounce ‘soda tax’ - Los Angeles Times https://www.latimes.com/science/sciencenow/la-sci-sn-soda-tax-works-20160823-snap-story.html 41.147 3/6 For instance, while Berkeleyites drank 26% less regular soda after the tax went into effect, their neighbors drank 10% more. The gap was even more pronounced in the case of sports drinks — those in Berkeley cut back by 36%, while those in Oakland and San Francisco drank 21% more. Both of those differences were large enough to be statistically significant, according to the study.

The trend lines were the same for other beverage categories. Interest in Arizona Iced Tea, bottled Frappuccinos and other sweetened coffees and teas fell by 13% in Berkeley, but rose 22% in Oakland and San Francisco.

Both groups of people consumed fewer energy drinks, though the reduction was greater in Berkeley (29%) than in the other two cities (14%). And while Berkeleyites consumed 13% fewer fruit drinks, their counterparts also cut back by 12%.

More than one in five Berkeley residents told the survey-takers that the tax had caused them to change their drinking habits. Among these 124 people, 82% said they consumed sugary drinks less frequently, and 40% said they had reduced their portion sizes.

The researchers didn’t translate these reductions into calories saved or pounds shed, so the policy’s effect on waistlines remains unknown. Nor could the team say for sure that the tax itself — and not the health messages that were discussed during the election campaign — was causing residents to shift from sugary drinks to water.

About 5% of people who said they had purchased sugary drinks in Berkeley before the tax went into effect told interviewers that they were now buying those drinks in other cities instead. Among these 18 people, six said the tax was the reason they made the switch.

Berkeley is a singular city, and it’s unclear how well these results would generalize to other cities and states, the researchers noted. But if a nationwide tax were to cut sugary 6/5/24, 5:56 PM Berkeley sees a big drop in soda consumption after penny-per-ounce ‘soda tax’ - Los Angeles Times https://www.latimes.com/science/sciencenow/la-sci-sn-soda-tax-works-20160823-snap-story.html 41.148 4/6 drink consumption by a similar amount, Americans as a whole could gain about 101,000 healthy years over a decade, according to another study cited by the researchers. “Widespread adoption of [sugar-sweetened beverage] excise taxes could have considerable fiscal and public health benefits,” they concluded. [email protected]
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Cardiologists: How Older Women Are Losing Weight Quickly American Women Over 40 Doing this Morning Coffee Ritual to Lose Weight! American Women Over 40 Doing this Morning Coffee Ritual to Lose Weight! 6/5/24, 8:43 PM Soda tax win in Oakland, San Francisco and Albany https://www.mercurynews.com/2016/11/08/voters-to-decide-on-oakland-albany-soda-tax-measures/amp/ 41.155 5/10 Concurring Statement of Commissioner Jon Leibowitz
Marketing Food to Children and Adolescents:

A Review of Industry Expenditures, Activities, and Self-Regulation (July 29, 2008)
Childhood obesity in America is now an alarming problem. The proportion of overweight children ages six to eleven has increased almost fivefold in the last generation, growing from four percent in the early 1970s to nineteen percent by 2004. One-third of our 1 youth ages two to nineteen are either overweight or at risk of becoming so. Overweight children 2 and adolescents are more likely to develop serious chronic diseases such as high blood pressure, high cholesterol, and Type 2 diabetes – and are more likely to become obese as adults. The 3 causes of childhood obesity, of course, are complex. A large part of the problem may have to do with changing lifestyles, more sedentary activities and less exercise. We all share some responsibility.

But to underscore the obvious, to some extent you are what you eat – and what children eat is influenced by what food is available and how it is marketed. Especially in an era with 4 more working parents who rely on restaurants, take-out, and quick-fix processed foods, industry can play an instrumental role in helping to curb the obesity epidemic. To be fair, most large food marketers are beginning to take their self-regulatory obligations seriously, and for that they deserve recognition. Yet some companies still need to step up to the plate and others need to strengthen their voluntary measures, not only because it is in the public interest, but also because it is in their self-interest: a failure of self-regulation may make the next Congress – and next administration – more inclined towards government regulation.5 Today’s landmark Report is a monumental feast of facts and figures about marketing food and beverages to children and adolescents. On a somewhat surprising note, the $1.6 billion in reported expenditures for food marketing to youth in 2006 (or almost $2 billion if the cost of toys provided with fast-food children’s meals is included) is much lower than previously estimated.

And some of the creative efforts to market milk, fresh fruits and vegetables, and to promote healthy diets and active lifestyles to young people are a pleasing sweet spot.

Equally noteworthy, however, the Report documents how highly sophisticated, fully integrated, multi-platform, cross-promotional advertising campaigns targeting children and teens are more pervasive than previously appreciated. Simply put, movie, television, and other entertainment tie-ins are ubiquitous. Although traditional television advertising still dominates, new means of Internet and digital advertising are becoming a major marketing force, as advertising spreads from television networks to social networks.

The Report includes two other findings that leave a tinge of heartburn. First, the disproportionate amount ($474 million) to market sugary carbonated beverages to adolescents is striking – that’s nearly $20 per American teenager in 2006. The marketing efforts must be 6 working; on average, adolescents get eleven percent of their calories from soft drinks. Studies 7

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show that those who drink more soda are more likely to become overweight. To their credit, the 8 major carbonated beverage marketers entered an agreement with the Alliance for a Healthier Generation and have committed to phase out the sale of full-calorie sodas in schools, shifting to lower calorie and more nutritious beverages. Wouldn’t a responsible next step be to extend this effort beyond the schoolhouse door, and curtail at least some marketing of full-calorie soft drinks to school-age youth – including teens – whether on television, via the Internet, in stores, or elsewhere?
Second, the big dollars to promote fast food restaurants to children are also somewhat hard to stomach: the $520 million for advertising and the toys included with fast food children’s meals was more than twice the amount spent by any other food category to target children under twelve in 2006. Some inner city low-income neighborhoods have numerous quick service 9 restaurants but few grocery stores or markets that sell nutritious foods, so many of the children most at risk for obesity rely on fast food as a mainstay of their diets. Studies show that over- 10 consumption of fast food likely contributes to overweight and obesity. I recognize that 11 McDonald’s and Burger King are working to develop new, lower calorie menu items for children. But surely more can be done to add options to fast food menus and improve families’ incentives to order healthier choices.

To be certain, food and beverage company participants in the Council of Better Business Bureaus’ Children’s Food and Beverage Advertising Initiative (“CBBB Initiative”) have made significant strides; not only formulating new and improved products, but also reformulating their advertising directed to young children to promote healthier food and lifestyle choices. They should be commended for taking this first, important step. However, joining the CBBB Initiative is just that – a first step – and there is still a long way to go. Almost exactly a year ago at the FTC and Department of Health and Human Services Forum on childhood obesity, several of us urged participating companies to extend their commitments to all of their child-directed marketing efforts, and to find a more appropriate way to measure when advertising is targeted to children. A year has passed and, although two more companies have joined the Initiative, little additional progress has been made to improve either the companies’ individual pledges or the Initiative’s core principles.

If the CBBB Initiative is to serve as the gold standard for self-regulation in food marketing, it needs to strengthen its guidelines. Company pledges should apply not just to measured media, but to all forms of marketing directed to children (which, as our Report tangibly demonstrates, are many). The Report confirms that television, radio, print, and Internet account for about sixty percent of marketing to young children – the CBBB Initiative and company pledges fail to cover the remaining forty percent spent on product packaging, point-of-sale, and other promotions. In addition, the CBBB should standardize the qualifications for “healthy dietary choices,” noting that “better for you” does not necessarily mean good for you. Moreover, a more appropriate standard for measuring a child audience could be created, bearing in mind that for a popular general audience show like American Idol, a modest percentage of children

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1. Centers for Disease Control and Prevention (“CDC”), Overweight and Obesity: Childhood Overweight: Overweight Prevalence,
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm (last visited July 17, 2008).

2. Cynthia L. Ogden, Margaret D. Carroll, Lester R. Curtin, Margaret A. McDowell, Carolyn J. Tabak & Katherine M. Flegal, Prevalence of Overweight and Obesity in the United States, 1999-2004, 295 JAMA 1594 at Table 2 (2006), available at http://jama.ama-assn.org/cgi/content/full/295/13/1549/JOC60036T2.

3. CDC, Overweight and Obesity: Childhood Overweight,
http://www.cdc.gov/nccdphp/dnpa/obesity/childhood/index.htm (last visited July 17, 2008).

4. See Institute of Medicine of the National Academies, Food Marketing to Children and Youth: Threat or Opportunity? at ES-6 to ES-7, 7-6 to 7-7 (2006) (“IOM Study”) (concluding that there is strong evidence that television advertising influences the food and beverage preferences, purchase requests, and consumption of children ages 2 to 11).

5. See, e.g., What the Candidates Had to Say, Wash. Post Online, May 18, 2008, http://www.washingtonpost.com/wp-dyn/content/article/2008/05/18/AR2008051801391.html (quoting the Obama campaign statement that, “If voluntary adoption [of guidelines for marketing of foods and beverages to children] is not effective, Obama believes that these guidelines should be made mandatory and that the Federal Trade Commission should have the authority and the resources to monitor and enforce compliance.”); see also IOM Study, supra note 4, at ES-12, 7-12 (“If voluntary efforts related to advertising during children’s television programming are unsuccessful in shifting the emphasis away from high-calorie and low-nutrient foods and beverages to the advertising of healthful foods and beverages, Congress should enact legislation mandating the shift on both broadcast and cable television.”).

6. Calculated based on projected U.S. census data for teens. U.S. Census Bureau, Population Division, Interim State Projections of Population by Single Year of Age: July 1, 2004 to 2030 (Apr. 21, 2005), watching translates into several million child viewers. Finally, the CBBB should create and implement a reliable system for monitoring company compliance.

Some in industry may criticize us for using our bully pulpit to encourage companies to do a better job of marketing healthier products to youth. Such criticism would be misguided. In many ways, industry self-regulation with encouragement from government is really a middle ground approach – somewhere between the government-mandated advertising restrictions adopted in some foreign nations (which might be subject to First Amendment challenge in this country) and the laissez-faire approach once urged by many in the business community. Indeed, especially here, a little government involvement – combined with a lot of private sector commitment – can go a long way toward the healthier future for our children that all of us want to see.

Endnotes

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http://www.census.gov/population/projections/DownldFile3.xls.

7. North Carolina School Nutrition Action Comm., Soft Drinks and School-Age Children: Trends, Effects, Solutions (July 2002) (citations omitted) (also stating that one-third of teenage boys drink at least three cans of soda each day, and that teenagers are drinking twice as much soda as milk), available at http://www.communityhealth.dhhs.state.nc.us/dental/ed_resources/Soft_Drinks_and_School_Age_Childr en.pdf.

8. A study by the Harvard School of Public Health found that for each additional serving of soda or juice a child consumes per day, the child’s chance of becoming overweight increases by 60 percent. See National Alliance for Nutrition and Activity, Obesity and Other Diet-Related Diseases in Children, http://www.cspinet.org/nutritionpolicy/Kidshealthfacts.pdf (last visited July 17, 2008) (citations omitted); see also Marvin E. Goldberg & Kunter Gunasti, Creating an Environment in Which Youths are Encouraged to Eat a Healthier Diet, 26 J. Pub. Pol. & Mktg. 162, 170-71 (2007) (noting the volume of sugared soft drinks that adolescents consume and citing studies finding an association between soft drink consumption and increased energy intake and body weight).

9. FTC, Marketing Food to Children and Adolescents: A Review of Industry Expenditures, Activities, and Self-Regulation at 20 (July 24, 2008) (“FTC Rept.”). Because consumers actually pay for the toy that accompanies many fast food children’s meals, companies responding to the FTC’s Special Order did not include the cost of these “self-liquidating” toys in their premium expenditure data. However, because the toy is a significant part of many marketing campaigns, FTC staff was able to estimate the cost of the premiums that quick service restaurants incur. If these costs are considered, expenditures for childdirected marketing by fast food restaurants exceeded $520 million. Id. at 19-20.

10. The Robert Wood Johnson Found. & Am. Heart Ass’n, A Nation at Risk: Obesity in the United States at 6, 23-24 (2005), available at
http://www.americanheart.org/downloadable/heart/1114880987205NationAtRisk.pdf. On average, youth ages 11 to 18 eat at fast food restaurants twice a week. Id. at 23. In 2006, quick service restaurants served more than 1.2 billion children’s meals with toys to children 12 and under. FTC Rept., supra note 9, at 19.

11. See, e.g., Shanthy A. Bowman, Steven L. Gortmaker, Cara B. Ebbeling, Mark A. Pereira & David S.

Ludwig, Effects of Fast-Food Consumption on Energy Intake and Diet Quality Among Children in a National Household Survey, 113 Pediatrics 112 (Jan. 2004); see also Marla Reicks, Fast-Food Consumption Among Minority Adults and Adolescents, Nutrinet (Univ. of Minn. Dep’t of Food Sci. and Nutrition), Jan. 2005, available at
www.fsci.umn.edu/pf/outreach/faculty_outreach/nutrinet/archives/january_2005/fast_food.html.

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Executive Summary
ES-1
Executive Summary
Concern about the dramatic increase in childhood obesity in the United States prompted Congress to request that the Federal Trade Commission conduct a study of food and beverage marketing to children and adolescents. The results of that study – an analysis of 2006 expenditures and activities by 44 companies – are presented here. Included are not only the traditional measured media – television, radio, and print – but also activities on the Internet and other new electronic media, as well as previously unmeasured forms of marketing to young people, such as packaging, in-store advertising, event sponsorship, and promotions that take place in schools. Integrated advertising campaigns that combine several of these techniques and often involve cross-promotions – linking a food or beverage to a licensed character, a new movie, or a popular television program – dominate today’s landscape of advertising to youth.

The data presented here tell the story of food and beverage marketing in a year just preceding, or early in the development of, industry self-regulatory activities designed to reduce or change the profile of such marketing to children. These initiatives – some of which grew out of a 2005 joint FTC and Department of Health and Human Services (HHS) Workshop on Marketing, Self-Regulation & Childhood Obesity – are described in Section IV of this Report, which also sets forth recommendations for future actions by food and entertainment industry members, as well as the organizations that have spearheaded self-regulatory efforts. This Report, which compiles information not previously assembled or available to the research community, may serve as a benchmark for measuring future progress with respect to these initiatives.

The data in this Report were obtained by issuing compulsory process orders to industry members, including beverage manufacturers and bottlers; companies that produce packaged food such as snacks, baked goods, cereals, and prepared meals; makers of candy and chilled desserts; dairy marketers; fruit and vegetable growers; and quick-service restaurants (QSRs). These are the foods most frequently advertised to children (ages 2-11) and adolescents (ages 12-17), and the 44 target companies are the primary marketers to youth (ages 2-17) in those food categories.

The companies were required to provide expenditure data in each of 20 advertising or promotional activity categories for marketing directed to children, adolescents, and all audiences.

Samples of marketing activities or descriptions of techniques used in 2006 were also obtained.

Dollars Spent on Marketing to Children and Adolescents
The 44 reporting companies spent approximately $1,618,600,000 to promote food and beverages to children and adolescents in the U.S. in 2006. Approximately $870 million was

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Marketing Food to Children and Adolescents
ES-2
spent on food marketing directed to children under 12 and a little more than $1 billion on marketing to adolescents. About $300 million of these expenditures were addressed to both age groups; hence, the total spending is less than the sum of the separate expenditures for the two age groups.

Previous estimates of food marketing directed to children and adolescents by other researchers have been significantly higher than $1.6 billion. There are several reasons for this disparity. Other researchers have not had access to the confidential company financial data obtained by the Commission. Moreover, prior estimates appear to have included advertising directed to children for products other than food. In addition, these estimates have included price promotions, such as coupons or discounts for children at hotels and restaurants, that generally are targeted to adults.

For those food and beverage brands promoted to children and adolescents, the overall expenditures for promotional activities directed to all audiences, including additional adultoriented marketing, was more than $9.6 billion. Therefore, the expenditures directed to those between the ages of 2 and 17 represented 17% of the total 2006 marketing budget for those brands.

Carbonated beverages, restaurant (QSR) food, and breakfast cereals accounted for $1.02 billion of the $1.6 billion, or 63% of the total amount spent on marketing to youth by the reporting companies. For carbonated beverages, the total was $492 million, with $474 million (or 96%) of that amount directed to adolescents. Nearly 24%, or $116 million, of carbonated beverage youth marketing consisted of in-school expenditures. QSRs reported spending close to $294 million on promotions to youth, divided fairly evenly between activities directed to children and those targeted to adolescents. For cereals, the total was $237 million, with $229 million targeted to children.

Television advertising still dominates the landscape of marketing techniques used to promote foods and beverages to youth; companies reported spending $745 million, or 46% of all reported youth marketing expenditures, on this medium. More than 50% of the television advertising was directed to children under 12, with breakfast cereals and restaurant food accounting for more than half of that advertising. Carbonated beverages and restaurant food dominated adolescentdirected television advertising. All told, traditional “measured media” (television, radio, and print) accounted for $853 million, or 53% of the reported youth-directed marketing expenditures.

New media – the Internet, digital (such as email and text messaging), and word-of-mouth/ viral marketing – have become an important component of promotional activities intended to reach children and adolescents. In an attempt to quantify the use of online marketing, Appendix

41.162
Executive Summary
ES-3
D to this Report explores the amount of display advertising for food and beverages that appeared on child- and adolescent-oriented websites in 2006, as well as traffic on company websites that promote food or beverage products through branded entertainment and activities designed for children and adolescents. In terms of expenditures, however, the new media accounted for only $77 million, or 5% of reported youth-directed marketing.

Expenditures on specialty items (premiums) and prizes for children and adolescents totaled $67 million, or 4% of reported youth marketing dollars. However, this number does not include toys distributed by QSRs with children’s meals because, in those cases, the consumer purchases the toy when paying for the meal. If the cost of QSR toys – which is estimated to total $360 million – were added to the reported premium expenditures, this category would jump to $427 million and would rank second only to television as a promotional technique targeted to children.

Moreover, if added to QSRs’ reported child-directed marketing expenditures of $161 million, these costs would result in total spending on child-directed marketing by the reporting QSRs of over $520 million – more than twice the amount spent on child-directed marketing in any other food category.

Companies reported spending $195 million on packaging and in-store display materials to reach children and adolescents, or 12% of all reported youth marketing expenditures. Marketing in schools totaled $186 million, or 11% of reported youth marketing, and 90% of those expenditures were for beverages, both carbonated and non-carbonated. The remaining $241 million (15%) of reported youth-directed marketing was spent on other traditional promotional activities, such as event and athletic sponsorships; celebrity endorsement fees; movie theater, video, and video game ads; product placements in movies, television, and video games; crosspromotion licensing fees; and promotional activities conducted in connection with philanthropic endeavors.

Expenditures for cross-promotions, including the use of licensed characters and tie-ins with television programs, movies, toys, or other entertainment events, were compiled across promotional categories – generally including television, the Internet, premiums, packaging, and in-store displays. A little more than $208 million, representing 13% of all reported youth marketing, was devoted to cross-promotions. For some food categories, such as restaurant food and fruits and vegetables, cross-promotions were nearly 50% of reported child-directed expenditures. Cross-promotional activities directed to children were used for restaurant food, breakfast cereals, snack foods, prepared foods, dairy products, baked goods, and fruits and vegetables. Cross-promotions targeting an adolescent audience were used for snack foods, candy, and carbonated drinks.

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Marketing Food to Children and Adolescents
ES-4
Methods of Promoting Foods and Beverages to Children
and Adolescents
For most food and beverage products, advertising to a young audience employs the full spectrum of promotional techniques and formats. Promotional campaigns directed to youth tend to be fully integrated, with themes encountered in television ads carried over to package materials, promotional displays in stores or restaurants, and the Internet. Packaging promotes the company or food product website, where entry of a code found on the package might enable the young consumer to participate in a contest, play a game that features the product, or receive “points” to redeem for premiums.

Cross-promotions were widespread in 2006, tying foods and beverages in all of the covered categories to about 80 movies, television shows, and animated characters that appeal primarily to youth. Superman Returns and Pirates of the Caribbean were prominent that year – promoting QSR children’s meals, frozen waffles, fruit and fruit snacks, breakfast cereals, popcorn, lunch kits, candy, carbonated and non-carbonated drinks, pasta, snack chips, and milk. Superman and the Pirates characters appeared in ads on television, in movie theaters, on the Internet, and on packaging and in-store displays. Companies created special limited edition snacks, cereals, frozen waffles, and candies based on the movies. Children or adolescents could go online to play “advergames” related to the characters and their stories and to enter contests or sweepstakes using special codes obtained from food packages or beverage containers. Prizes ranged from video games to trips to Disney parks to a $1,000,000 reward for the “capture” of Superman villain, Lex Luthor. Related premiums included skull-shaped bowls, bandanas, strobe light key chains, movie posters, outdoor flying toys, Superman action figures, activity books, and digital downloads.

For some food products marketed to children, companies have created their own successful “spokescharacters” – animated versions of animals, people, or even the food itself. Stories and biographical information about the characters appear in television ads, on packages, and in online videos. The stories are augmented by websites that use the characters in games, afford children the opportunity to help them solve problems or mysteries, and offer related prizes or premiums, such as character cards or comic books to collect. Food company characters occasionally even make “live” appearances at events. Some food companies also sell – or license third parties to sell – merchandise, such as toys and clothing branded with food products or their spokescharacters.

The Internet – though far less costly than television – has become a major marketing tool of food companies that target children and adolescents, with more than two-thirds of the 44

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Executive Summary
ES-5
companies reporting online, youth-directed activities. Some devote space on a company website to child or adolescent content, while others have developed independent websites for foods or beverages that particularly appeal to children or adolescents. Advergames, directed to both children and adolescents, were featured on websites for snacks, cookies, candy, cereals, dairy products, frozen meals, beverages, soups, frozen waffles, fruit, and restaurant food.

Websites appealing to adolescents often featured sports or music, and many offered free downloads, such as screensavers, wallpapers, ringtones, music, and layouts for MySpace pages. Downloads for children included activity sheets, pages to color, stickers, iron-on decals, and games. Some beverage companies contacted adolescents by text messaging, and a few companies used podcasts and “webisodes” (online video episodes) to reach children and adolescents.

A by-product of Internet marketing is viral marketing, in which consumers are encouraged to share electronic promotional messages with other consumers. Typically, these efforts consist of “e-cards” (electronic greeting cards) and “send-to-a-friend” emails that can be sent from food product websites and contain hyperlinks back to the site. These techniques were used to reach both children and adolescents, and often were linked to a cross-promotional campaign. Word-ofmouth activities involved electronic and non-electronic peer-to-peer communications about food products, in which consumers were recruited to act as product “ambassadors” or “connectors” by handing out promotional materials or samples. Most of these activities were directed to adolescents.

Product packages and point-of-sale materials in stores were used heavily for movie or television program cross-promotions, displays of company spokescharacters, and premium or sweepstakes promotions. Sports themes and offers of sports paraphernalia were a popular means of attracting adolescent consumers. Other store promotions featured mini-events, with branded vehicles, product samples, carnival-type activities for children, and distribution of toys or other items. Fruit and vegetable companies used Sesame Street and other characters on produce displays, packaging, and the produce itself to appeal to young children.

Premiums – available free with the food product or at a discount with proof of purchase – ran the gamut from small toys, trinkets, or collectible cards to DVDs, video games, music or ringtone downloads, and amusement park or event tickets. Prizes available through contests or sweepstakes were often in the form of cash. Other prizes included electronic equipment, such as televisions, digital music players, and cell phones; sports equipment, apparel, camps, or clinics; vacations and trips to theme parks; and tickets to concerts or sporting events. Some companies

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offered a point system tied to accumulated proofs of product purchase; points could be redeemed for merchandise, usually through a company website.

Celebrity endorsers – actors, athletes, singers, and musical groups – were featured in television and print ads, on the Internet, and in store displays, primarily in ads directed to adolescents or “tweens” (those between the ages of 8 or 9 and 13 or 14). Often they were tied to sweepstakes, such as a contest for the opportunity to meet a basketball star in person. Food and beverage promotion took place at sponsored events, including local fairs or festivals with children’s activities, performances at mall and retail sites, concerts, athletic events, circuses, children’s movie premieres, and other venues appealing to children or adolescents. Some companies sent branded cars, vans, or buses on tour to distribute samples and engage with children or adolescents at stores, community events, amusement parks, athletic events, or “impromptu” events created by the food marketer itself. Sponsorship of athletes, athletic teams, and competitive sporting events, including those for extreme sports, was a common promotional activity directed to children or adolescents. The sponsorship of professional athletic teams also included opportunities for children or tweens to meet players, participate in pre-game or sideline events, and attend sports camps, clinics, or training programs.

Product placements – such as a character drinking a soda or offering it to another character, a can or bottle appearing on a table, or a brand name mentioned in dialogue – occurred in a few television programs popular with children or adolescents and in some PG and PG-13 movies appealing to youth. Food and beverage ads also appeared in movie theaters, on videos, and before video games, and occasionally food products were integrated into video game content.

Marketing in elementary, middle, and high schools occurred primarily through displays on or around vending machines or in cafeterias. Companies sponsored athletic events, programs, equipment, or apparel; provided product samples and branded merchandise to schools; and sometimes sponsored contests with student prizes. A few provided instructional materials about nutrition and fitness or sponsored reading encouragement programs.

Food Company Health Initiatives
Since the 2005 FTC/HHS Workshop on Marketing, Self Regulation & Childhood Obesity, and the subsequent Report issued in April 2006, members of the food and beverage industry, as well as entertainment and media companies, have taken important steps to encourage better nutrition and fitness among the nation’s youth. The Children’s Food and Beverage Advertising Initiative, established by the Council of Better Business Bureaus (CBBB) in November 2006, represents a significant effort to change the mix of food and beverage advertising messages

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Executive Summary
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directed to children under 12 and to encourage them to eat healthier foods and be more physically active. To date, 13 of the largest food and beverage companies – estimated to account for more than two-thirds of the food and beverage television advertising expenditures directed toward children – have joined the Initiative, pledging either not to direct television, radio, print, or Internet advertising to children under 12 or to limit their advertising to foods that meet specified nutritional standards. Other aspects of the pledges include limiting the use of licensed characters to the promotion of healthier products or lifestyles, not seeking product placements in child-directed media, not advertising food or beverages in elementary schools, and using only “healthy dietary choices” in interactive games directed to children.

The Alliance for a Healthier Generation – a partnership of the William J. Clinton Foundation and the American Heart Association – has joined with industry in a significant effort to change the array of “competitive” foods and drinks (i.e., those sold outside the school meal program) sold to children and adolescents in schools. The School Beverage Guidelines, adopted in May 2006, impose size and calorie limitations that vary based on educational level. The Competitive Food Guidelines, adopted in October 2006, impose restrictions on calories, as well as fat, sugar, and sodium content.

Other efforts by food industry members include: product reformulation; development of new “better for you” products; more nutritious products available in QSR children’s meals; single-serving packages to assist with portion control; nutritional labeling initiatives, such as company icons, third-party seals, and front-of-package nutrition information; and public education directed to children and adolescents regarding nutrition and fitness. Some media and entertainment companies have also stepped forward with new initiatives, such as limiting the licensing of popular characters to promote only foods meeting minimum nutritional requirements; requiring program sponsors to meet nutritional guidelines; and incorporating healthy messages into children’s programs.

The Commission notes that significant progress has been made in implementing the recommendations that evolved from its 2005 Workshop and 2006 Report, although there remains room for improvement. Based on the results of this study, the Commission has developed the following recommendations for future actions by industry members and others, including the organizations that have undertaken new initiatives to address the childhood obesity problem:

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Recommendations for Food and Beverage Companies
GENERAL:
• All companies that market food or beverage products to children should adopt and adhere to meaningful nutrition-based standards for marketing their products to children under 12. A useful first step would be to join the CBBB Initiative. • Companies should broadly construe “marketing” to include all advertising and promotional techniques, including but not limited to: advertising on television and radio, in print media, and on the Internet (including third-party and company-sponsored websites); product packaging and labeling; advertising preceding a movie shown in a movie theater or placed on a video (DVD or VHS) or within a video game; promotional content transmitted to personal computers and other digital or mobile devices; advertising displays and promotions at the retail site; specialty or premium items distributed in connection with the sale of a product; promotion or sponsorship of public entertainment events; product placements; character licensing, toy co-branding and cross-promotions; sponsorship of sports teams or individual athletes; word-of-mouth and viral marketing; celebrity endorsements; and in-school marketing. • In cases where a product line contains some product varieties that meet the nutrition-based standard and others that do not, companies should strictly limit all components of a promotion or advertising campaign directed to children under 12 to those varieties that meet the standard. Thus, for example, television or print advertisements promoting a sweepstakes would feature only the “better for you” varieties of the product, and licensed characters would appear only on packages of the “better for you” varieties.
• Companies should consider limiting branded merchandise intended for children to products or brand lines meeting meaningful nutrition-based standards.

IMPROVING THE NUTRITIONAL PROFILE OF PRODUCT OFFERINGS:
• Companies should continue and increase efforts to improve the nutritional profiles of their products – especially those marketed to children and adolescents – through product innovation and reformulation.
• Companies should improve upon the nutritional criteria adopted for “better for you” products as they find ways to lower sugar, fat, sodium, etc., without sacrificing taste and appeal.
• In applicable cases, companies should re-examine whether the fact that a product has “less” of, or is “reduced” in, calories or certain nutrients (e.g., sodium, sugar, or fat) is, by itself, a sufficient basis for qualifying as a “better for you” product.

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Executive Summary
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• Companies should continue and expand efforts to package more nutritious products in ways that are more appealing to children.
• Companies should continue efforts to use product packaging to help consumers control portion sizes and calories, by offering smaller portions and single-serving packages.

NUTRITION LABELING:
• Companies should conduct research on the effectiveness of various labeling devices to determine how consumers interpret such labeling and to identify those devices most effective at conveying meaningful, truthful information. • Companies should work toward consistency among the standards used by individual food and beverage companies to determine what constitutes a “better for you” product, such as through the development and use of third-party standards, icons, or other devices. The Commission supports the work of the Keystone Center and others in this regard.

HEALTHY MESSAGES:
• Companies should expand public outreach efforts – through company-sponsored initiatives, third-party partnerships, and innovative and varied media techniques – to educate children and adolescents about the importance of healthy eating and exercise.
• Companies should devote particular attention to outreach aimed at ethnic minority populations that are disproportionately affected by childhood overweight and obesity.
• Companies should continue researching the effectiveness of their campaigns to educate and motivate youth to engage in healthier lifestyles.

THE CBBB INITIATIVE:
• The CBBB should closely monitor participating companies’ compliance with their pledges.
• The CBBB and participating companies should enhance the Initiative in the following ways:
• Expand the scope of “advertising to children” to encompass all advertising and promotional techniques, including, for example, product packaging and in-store marketing;
• Require that 100% of food advertising directed to children under 12 promotes healthy dietary choices;

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• In cases where a product line contains some product varieties that meet a company’s nutrition criteria for a “healthy dietary choice” and others that do not, the company should strictly limit all components of a promotion or advertising campaign directed to children under 12 to those varieties that meet the criteria.

Thus, for example, television or print advertisements promoting a sweepstakes would feature only the varieties of the product that represent healthy dietary choices, and licensed characters would appear only on packages of the varieties that are healthy dietary choices.
• Work toward standardizing the nutrition criteria for “healthy dietary choices” that may be marketed to children, such as by product category (e.g., for beverages, cereals, snack foods, soups, canned pastas, frozen entrees, etc.); • In applicable cases, companies should re-examine whether the fact that a product has “less” of, or is “reduced” in, calories or certain nutrients (e.g., sodium, sugar, or fat) is, by itself, a sufficient basis for qualifying as a “healthy dietary choice”; • Work toward developing meaningful, standardized definitions for what constitutes advertising “directed to children under 12.” In considering how to define “directed to children,” the CBBB and participating companies should consider, where relevant to the advertising medium, factors such as the percentage of the audience under 12; the total number of children reached; the time of day and venue in which the advertising appears; and whether the advertising features characters, performers, or celebrities who are popular with children, or contains themes, language, or other attributes designed to appeal to children.
• Require companies not to engage in, approve, or allow placement of their product in media directed to children under 12;
• Require participating companies to ensure that their franchisees are bound by the companies’ pledge commitments, such as by incorporating the pledge commitments into any franchisee contracts.

FOODS & BEVERAGES IN SCHOOLS:
• Companies should continue efforts to improve the nutritional profile of foods and beverages sold in schools.
• All companies that sell “competitive” food or beverage products in schools should join the Alliance for a Healthier Generation or otherwise adopt and adhere to meaningful nutrition-based standards for foods and beverages sold in schools, such as those recommended by the Institute of Medicine.
• Participating companies should consider incorporating their Alliance commitments into distributor contracts.
• Companies should cease all in-school promotion of products that do not meet meaningful nutrition-based standards.

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Executive Summary
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• The Commission encourages schools and school districts, as part of their school wellness policies, to adopt and implement meaningful nutrition-based standards for competitive foods sold in schools.

Recommendations for Media and Entertainment Companies
• More media and entertainment companies should limit the licensing of their characters to healthier foods and beverages that are marketed to children, so that cross-promotions with popular children’s movies and television characters will favor the more, rather than the less, nutritious foods and drinks. • Media companies should consider adopting uniform, objective standards that limit advertising placements on programs “directed to children” to healthier food and beverage products.
• Media and entertainment companies should continue to incorporate health and nutrition messages into programming and editorial content, and to create public education campaigns aimed at the problem of childhood obesity. • Media and entertainment companies should test the effectiveness of any health and nutrition messages and public education campaigns aimed at the problem of childhood obesity.
• Media and entertainment companies should consider the feasibility of instituting a self-regulatory initiative to facilitate implementation of the recommendations above.

The companies should consider working with the CBBB in this endeavor.

Conclusion
The food and beverage companies surveyed for this Report spent more than $1.6 billion marketing their products to children and adolescents in 2006. The Commission believes that these companies were responsible for a substantial majority of the industry expenditures for food and beverage marketing to children and adolescents during 2006. The companies used myriad techniques, including traditional measured media, the Internet and other “new” media, as well as product packaging, in-store advertising, and event promotions, to name a few. Integrated advertising campaigns that combined several of these techniques were prevalent.

Whether there is a link between food marketing to children and childhood obesity is a question not addressed by this Report. What is clear, however, is that childhood obesity is a complex problem, with many social and economic contributing factors. The Commission believes that all segments of society – parents, schools, government, health care professionals, food companies, and the media – have an obligation to contribute to finding and implementing solutions. This Report – with its detailed assessments of the kinds of foods being marketed to

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children and adolescents and how these foods are being marketed – informs one aspect of the ongoing dialogue about how to address the problem.

Participants in the 2005 Workshop generally agreed that, regardless of the causes of childhood obesity, food and beverage marketers can employ a wide range of strategies to play a positive role in reversing the trend. Participants also recognized that consumers expect the industry to help both adults and children improve their diets by providing more healthy choices and helpful nutrition information, and by engaging in responsible marketing practices. Based on this study, the Commission has formulated its recommendations for future actions by members of the food industry, the media and entertainment industries, and others. These recommendations, set forth above, are also included in Sections IV and V of the Report.

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1 Lindsay Nelson
From: Judi Grunstra <[email protected]>
Sent: Friday, June 21, 2024 5:57 PM
To: City Council
Subject: Agenda Item 41_Sugary beverage tax
To the Mayor and Council:

I am opposed to this tax. Food prices are already very high. There is plenty of information available to inform consumers of the calorie and sugar content of any beverage for sale on supermarket shelves or in fast food restaurants. Parents should guide their children in nutritional matters, and they are free to NOT purchase unhealthy foods, which includes sugary cereals, juice (more sugar than eating a fruit), not to mention the shelves full of salty snacks. If a parent is letting a baby drink sugary drinks, shame on them.

Don't make all consumers pay for the poor choices of others.

Judi Grunstra

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2 Lindsay Nelson
From: Rachel Dann <[email protected]>
Sent: Monday, June 24, 2024 1:01 PM
To: City Council
Subject: Item #41 Sugary Beverage Tax
Dear Mayor and Councilmembers,
I am writing as a resident of the City of Santa Cruz to express my strong support for item #41 which would place a tax per ounce on sugary beverages sold in Santa Cruz. There is ample evidence to show that placing even a modest tax on harmful sugary drinks has positive health benefits. The staff memo does an excellent job outlining this evidence and showing how similar measures passed in other jurisdictions have led to improved health outcomes and less consumption of sugary beverages. In addition, this tax will generate funds for youth and community recreation, as well as other public benefits and will also act as a vehicle to further educate our community of the negative effects of sugary beverages, especially on our youth. This proposed measure has been well researched, vetted with the community, and has a broad coalition of support that has been built over time. I am gratified that Councilmembers Watkins, Brunner and Kalatari-Johnson have brought it forward and hope the proposal receives a unanimous vote..

I look forward to supporting this measure come November.

Sincerely,
Rachel Dann

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3 Lindsay Nelson
From: Bonnie Bush
Sent: Monday, June 24, 2024 4:20 PM
To: City Council
Subject: Fwd: Item 41 on Santa Cruz City Council Agenda -- June 25, 2024 Bonnie Bush
City Clerk
City of Santa Cruz
809 Center St., Room 8, Santa Cruz, CA 95060
Phone: 831-420-5035
Email:[email protected] Web: www.cityofsantacruz.com Begin forwarded message:

From: Casey Beyer <[email protected]>
Date: June 24, 2024 at 4:14:42 PM PDT
To: Fred Keeley <[email protected]>, Renee Golder <[email protected]>, Sandy Brown <[email protected]>, Sonja Brunner <[email protected]>, Shebreh Kalantari-Johnson <[email protected]>, Scott Newsome <[email protected]>, Martine Watkins <[email protected]> Cc: Bonnie Bush <[email protected]>, Matt Huffaker
<[email protected]>
Subject: Item 41 on Santa Cruz City Council Agenda -- June 25, 2024 Dear Mayor Keeley, Vice Mayor Golder and Councilmembers Brown, Brunner, KalantariJohnson, Newsome and Watkins:

I am writing as a private citizen (not as the CEO of the Santa Cruz County Chamber) about Item 41 — City Council Sugar-Sweetened Beverage Ad Hoc Committee Recommendations Related to the Placement of a General Purpose Tax Measure of Two-Cents Per Ounce on Distributors of Sugar-Sweetened Beverages on the November 5, 2024 Ballot. The timing of this item set for the June 25th council agenda (from its posting last Friday) does not provide adequate time for the Chamber to thoroughly review the merits of the proposal prior to a Council vote. The Chamber will remain silent at this time. If the Council approves this item and moves it to the November ballot the Chamber reserves the right to hear from both the proponents and the opponents of the measure. Based on those conversations, the Chamber may choose to take a position.

I have followed this issue carefully prior to the 2018 decision when the State Legislature passed this legislation (the Keep Groceries Affordable Act) and Governor Jerry Brown signed the legislation into law thus establishing the moratorium on the excise soda tax until January 2031. While the court decision in Cultiva La Salud v. State of California opens the door for the City Council to move forward with a soda tax, there numerous issues that need to be clarified.

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4 What is not clear is whether the court decision vacates the entire act. According to the provisions of the act, The California Department of Tax and Fee Administration shall not administer and shall terminate its contract to administer any sales or use tax ordinance of a local agency under the Bradley-Burns Uniform Local Sales and Use Tax Law (Part 1.5 (commencing with Section 7200)) if that local agency imposes, increases, levies and collects, or enforces any tax, fee, or other assessment on groceries, as defined in subdivision (g) of Section 7284.10, for which a court of competent jurisdiction has determined both of the following:
(1) The tax, fee, or other assessment is in conflict with the prohibition set forth in subdivision (a), and is not a tax, fee, or other assessment described in subdivision (b) or (d).
(2) The tax, fee, or other assessment is a valid exercise of a city’s authority under Section 5 of Article XI of the California Constitution with respect to the municipal affairs of that city.
7284.14. Severability of provisions. If any provision of this chapter or its application to any person or circumstance is held invalid, the remainder of the chapter or the application of the provision to other persons or circumstances is not affected.

It appears that the court decision does not affect the Bradley-Burns Uniform Local Sales and Use Tax Law.

As the City Council discusses Item 41 on Tuesday afternoon, I believe these questions need clarification from the City Attorney:
1) Does the Bradley-Burns Uniform Local Sales and Use Tax Law still apply to charter cities and non charter cities?
2) If the current state law is in place and the city council approves the Item for the November ballot — is there a possibility of a legal challenge? 3) Has the City conducted a financial analysis for the potential cost of defending the city against a legal challenge?
4) If the ballot measure receives voter approval and faces a legal challenge, can the city collect the excise tax during the period of court challenges? While I appreciate the ad-hoc committee’s report and reference to doing public outreach before submitting this item for consideration at the city council, norted here: The Ad-Hoc Committee has conducted outreach to stakeholders over the past year including American Lung Association, American Heart Association, Santa Cruz Seaside Company, Santa Cruz City Schools, Santa Cruz County Office of Education, County Health Department, Dientes Community Dental, Health Improvement Partnership, Black Health Matters, Community Action Board, United Way Santa Cruz,

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5 as well as other leaders in business, healthcare, dental and medical care industry to gather input on the placement of the tax measure on the ballot.

To my knowledge, no one from the Ad-hoc committee directly reached out to the Chamber of Commerce or our members (except to the Seaside Company and our non-profit members). Some of our members may be affected by this tax and should have been contacted for their input. I received communication from the city manager just a week or so ago. I appreciate that he reached out, but it was a forgone conclusion that the city council as set to move forward with further community engagement. It appears that little effort was given to discuss the council agenda item with local grocery stores, restaurants and other businesses that serve a sugary beverages. Is their input not necessary for fear that there would be a difference of opinion.

I appreciate the ad-hoc committee’s wholistic approach to address the health benefits of this policy. I do not question those intentions. However the ad-hoc committee failed to thoroughly study the economics of such a tax. The City Council would have been better options to educate the residents of Santa Cruz and the voters by using an independent analysis such as the 2018 LAO report: https://lao.ca.gov/Publications/Report/3903. That report offers additional information that should be consider. Here are a few citations in the report:

Excise Taxes Not an Ideal Way to Raise Revenue. As fiscal tools, excise taxes have several shortcomings, including:
 Undue Burdens. The cost of funding basic government services is generally borne by the entire public—based on broad measures such as income and wealth. An excise tax, on the other hand, is borne by a narrowly defined group of businesses or consumers. As such, the tax burden can be disproportionately borne. For instance, excise taxes are usually regressive, meaning lower-income people tend to spend a higher share of their incomes on the tax than higher-income people.  Political Competition. Narrowly targeted tax policies make businesses’ success less dependent on competition in the marketplace and more dependent on competition for favorable policy treatment.

Consider Administrative Burden. In addition to the fiscal goal of raising revenue and the policy goal of improving health, the design choices listed above hinge on a third factor:
the administrative burden imposed by the tax. To account for this factor, policymakers should ask two questions of any tax proposal:
 Can tax administrators and taxpayers implement the tax successfully? (For simplicity, we use the term “taxpayers” to refer to businesses that would register and remit the tax. As discussed below, however, consumers would pay much of the tax indirectly through price increases.)
 How difficult is it for taxpayers to comply with the tax?

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6  Local excise taxes tend to be less effective fiscal and policy tools than statewide or national excise taxes for two reasons:
o Cross-Border Shopping. Some consumers respond to the tax by buying the taxed good in other jurisdictions instead of reducing their consumption. o Price Setting. Large retail chains often set prices on a regional basis.

Consequently, a modest tax that covers only a small area might not lead such chains’ stores to raise their prices.

There are so many unanswered questions that would occur once and if the ballot measure is approved by the voters. Dynamic economic modeling leads to some compelling human behaviors. When a product is taxed there is a tipping point where the consumer responds by limiting the use of the product or in some instance completely stop that consumption. The second most likely outcome is the consumer will find the product outside of the taxing jurisdiction. Thus the tax collected will fall — a real example is:

Excise Tax Revenue and Program Costs Often Diverge Over Time. When policymakers link a program’s budget to revenue from a specific tax, the resulting funding often diverges from program costs over time.
 Example: First 5 California. First 5 California—which funds services for children under 5 years old—receives the vast majority of its funding from tobacco taxes, 50 cents on a pack of cigarettes. Pop. 10 was designed to fund local governments and the state based the number of births in California—the main factor determining the number of children served by First 5—has remained roughly constant over time.

Real tobacco tax revenue, however, has declined steadily over time. One important factor as the need for services goes up in a bell curve, the funding source is a reverse bell curve— see the tab below:

I appreciate the ad-hoc committee’s work but if the real intent is to have robust public stakeholder input, waiting until the item becomes a ballot measure is not the best approach to public policy.

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7 I want to underscore that the Chamber is not taking a position on the city council Item 41, but offering information that I believe is helpful to the city council discussion and to educate the public and city voters. They deserve to know the full scope of the tax benefits and risks.

Respectfully

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8 Casey Beyer
[email protected]

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9 Lindsay Nelson
From: Maya Peterson <[email protected]> on behalf of Maria Elena de la Garza <[email protected]> Sent: Monday, June 24, 2024 4:30 PM
To: City Council
Subject: Santa Cruz City Council - Agenda Item 41 Sugar Beverage Tax Good Afternoon,
I am writing to you on behalf of the Community Action Board of Santa Cruz County, Inc. (CAB). As a member of the national Community Action Network, as well as the County’s designated community action agency since 1965, CAB strives to eliminate poverty and create social change through advocacy and essential services. CAB strongly urges your Council to support placing a sugar-sweetened beverage (SSB) tax measure on the upcoming November ballot.

Studies have consistently shown that sugar-sweetened beverages are the leading source of excess and unhealthful calories in the diets of children, contributing significantly to the obesity crisis. Since the 1970s, these beverages have become the top caloric contributor to childhood obesity. Medical professionals are now encountering diseases in overweight children that were once only seen in adults, such as Type 2 diabetes, which has skyrocketed across all age groups.

The success of tobacco taxes in reducing consumption serves as a compelling model for the potential impact of an SSB tax. The revenues generated by tobacco taxes have helped to fund successful public health campaigns that have reduced tobacco use. By discouraging the consumption of sugary drinks, we can make substantial progress to improve public health outcomes, to give our children the knowledge to protect themselves, and to reduce ever escalating healthcare costs resulting from the expansion of preventable disease. Local control over the implementation and allocation of an SSB tax ensures that the generated revenue can be used effectively to address the specific public health needs of the community and strengthen partnerships with Community Based Organizations who work with vulnerable communities. Introducing a tax on sugar-sweetened beverages is not just about economics; it’s a proactive step towards safeguarding public health. By taking this step, city leaders and residents can show their commitment to the health and wellbeing of our children and future generations.

By giving Santa Cruz residents the opportunity to vote on this important public health initiative, the election process itself will stimulate greater public awareness and discourse on how best to protect the health and welfare of the community. I strongly urge your support by voting to place the sugar-sweetened beverage tax measure on the November ballot.

Thank you for your consideration.

In Community,
PLEASE BE SAFE: WEAR A MASK; KEEP 6 FEET APART; SHELTER IN PLACE; WASH YOUR HANDS; CELEBRATE SAFELY

MaríaElena De La Garza
Chief Executive Officer

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10 Community Action Board of Santa Cruz County, Inc.
406 Main Street, Suite 207, Watsonville, CA 95076
Office: 831.763.2147 Ext. 203 | Fax: 831.724.3447
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41.182
11 Lindsay Nelson
From: Bonnie Bush
Sent: Monday, June 24, 2024 4:57 PM
To: City Council
Subject: Fwd: SSB Ballot Measure - 6/25/2204 Agenda
Attachments: Santa Cruz SSB Ltr.pdf
Bonnie Bush
City Clerk
City of Santa Cruz
809 Center St., Room 8, Santa Cruz, CA 95060
Phone: 831-420-5035
Email:[email protected] Web: www.cityofsantacruz.com Begin forwarded message:

From: Tim James <[email protected]>
Date: June 24, 2024 at 4:48:17 PM PDT
To: Fred Keeley <[email protected]>, Renee Golder <[email protected]>, Sandy Brown <[email protected]>, Sonja Brunner <[email protected]>, Shebreh Kalantari-Johnson <[email protected]>, Scott Newsome <[email protected]>, Martine Watkins <[email protected]> Cc: Bonnie Bush <[email protected]>
Subject: SSB Ballot Measure - 6/25/2204 Agenda
Councilmembers, Please accept the attached letter regarding the Sugar-Sweetened Beverage Tax Measure. Thank you for your consideration and contact me for discussion or questions. Thank you, Tim Timothy James
Director, Local Government and Enterprise Risk
California Grocers Association
916-448-3545

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June 24, 2024
The Honorable Fred Keeley
Mayor, City of Santa Cruz
809 Center Street
Santa Cruz, CA 95060
RE: Sugar-Sweetened Beverage Ballot Measure
Dear Mayor Keeley,
On behalf of the grocery industry, I write with significant concerns regarding the Sugar-Sweetened Beverage Tax Measure.

There are numerous implementation and operational impacts which will significantly increase the cost to the cost of groceries in Santa Cruz. In addition, the process for consideration has been significantly lacking including a lack of engagement with grocers and clear and accurate discussion of the Keep Groceries Affordable Act.

This proposal is simply and clearly a tax on grocery stores. It is not a tax directly placed on the described product. The tax measure will increase the cost to operating a grocery store, which is everyone’s primary source for fresh, nutritious and healthy food. The cost of food and grocery items has climbed in recent years due to residual pandemic impacts, supply chain restrictions and overall inflation. Currently consumers are paying more than ever for food, while grocery profits remain below the long standing 2.5% mark. Increasing the costs to operate grocery at this time is short sighted and ill advised.

The Agenda Report identifies significant outreach to stakeholders, yet does not mention grocery or grocers even once. It is beyond concerning that impacted Santa Cruz grocers were not informed, included, or approached in a meaningful way during this process. We believe, and hope the Council agrees, that public policy is best served when inclusive, even when disagreements may arise.

As presented, grocery went unheard and unrecognized by members of the Ad Hoc Committee. The omission of regulated grocery businesses deserves both an explanation and, most importantly, a correction. We request the measure not move forward until a meeting with the Ad Hoc Committee and impacted grocers occurs to ensure an informed, responsible and inclusive policy discussion.

Presntation of the Keep Grocers Affordable Act (Act) and its impact on the measure is incomplete in the Agenda Report. As stated, the Act prevents local agencies from imposing new taxes of this type. It is also accurate that the penalty portion of The Act was removed. The missing discussion is the preemption on local agencies being prevented from passing these types of taxes was not invalidated.

By placing this tax measure on the ballot the Council is walking the community through an election process while knowingly making promises that cannot be kept. Without recognition of the legal scenario in the Agenda Report we believe both the discussion and consideration of this measure is beyond lacking and bordering on irresponsible. Again, we request the measure not move forward until the public, stakeholders and the Council are fully aware of this jeopardy.

Thank you for your consideration and we look forward to further discussion and analysis before moving forward.

Sincerely,
Tim James
Director, Local Government Relations
California Grocers Association
cc: Members, Santa Cruz City Council

41.184
Sugar-Sweetened Beverage
Ballot Proposal
SSB Ad Hoc Committee: Councilmembers Brunner, Kalantari-Johnson, Watkins

41.185
Global Context
Over 50 countries have implemented
taxes on sugar-sweetened beverages
(SSBs).

Introduction &
Background
2018 Santa Cruz Initiative:

In June 2018, the Santa Cruz City
Council approved a one-cent per
ounce SSB tax ballot initiative. The
initiative was halted when Governor
Jerry Brown signed the Keep
Groceries Affordable Act in late June
2018.

The Keep Groceries Affordable Act:

Prevented local agencies from imposing new
taxes on certain grocery items, including SSBs.

Included severe penalties, such as loss of all sales
and use tax revenue, for any city implementing
new grocery-related taxes.

Legal Challenge:

Cultiva La Salud and Councilmember Martine
Watkins sued the state, arguing the Act’s
penalties were unconstitutional. In 2023, the
Third District Court of Appeal struck down the
penalty provision, deeming it an unconstitutional
threat to charter cities.

Current Status:

In May 2023, the City Council appointed a
Sugar-Sweetened Beverage Ad Hoc Committee
to explore the feasibility of a new SSB tax
measure for the March or November 2024
ballot.

41.186
https://sites.psu.edu/siowfa15/2015/12/02/sugarsweetened-drinks-cause-heart-disease/ 41.187 Health Disparities
• 40% of all children may develop Type 2
diabetes
• For Latino and African American children,
the rate is 50%.
• Infants who drink sugary drinks have an
83% chance of cavities at age 6.
• Two in three California teenagers drink at
least one soda daily.
• Marketing and Consumption
⚬ Beverage Companies: Target youth and
communities of color with sugary drinks.

Impact on
Vulnerable
Populations
Santa Cruz Goals: Reduce sugary drink
consumption, promote healthier habits, and
improve well-being.

41.188
Health Risks and Local Health Data
Local Health Data:
• Santa Cruz County:
⚬ More overweight children compared to California average. ⚬ Adult obesity highest among Latinos.
⚬ Dominican Hospital Report: “Healthy weight is a significant issue in Santa Cruz County, with a larger proportion of children who are overweight for their age compared to all California children. In addition, adult obesity... [is] highest among the county’s Latino population.”
SSBs are the leading source of added sugars in the American diet.

41.189
• First California City
to implement SSB tax
in March 2015.
• Results: 9.6%
decrease in soda
consumption, 15.6%
increase in water
consumption.
• Highest sugary drink
consumption among
youth, young adults,
and ethnic minorities.
• Preliminary data
showed reductions in
sugary drink
consumption and
increases in water
consumption.
• After excise taxes on
sugary beverages,
purchases declined by
33% (across five
Cities in the U.S).

Case Study: Berkeley Case Study: San Francisco UC Berkeley Study

41.190

41.191
Engagement
Stakeholder Outreach Conducted:
•Health organizations
•Schools
•Community groups
•Businesses

41.192
Ba llo t
La n g u a g e
& De ta ils
RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SANTA CRUZ:
(1) ORDERING AN ELEC TION ON A MEASURE TO DETERMINE W HETHER THE C ITY SHOULD IMPOSE A TAX OF TW O C ENTS ($ 0 .0 2 ) PER FLUID OUNC E ON THE DISTRIBUTION OF SUGAR SW EETENED BEVERAGE PRODUC TS; (2 ) REQUESTING THAT THE SANTA C RUZ C OUNTY C LERK/ ELEC TIONS DEPARTMENT C ONDUC T THE ELEC TION FOR SAID MEASURE; AND (3) REQUESTING C ONSOLIDATION W ITH THE NOVEMBER 5, 2 0 2 4 GENERAL ELEC TION.

41.193

EXEMPTIONS
• Small businesses
• Products: Diet soda, natural juices, milk and milk substitutes, diet supplements and alcohol
• ONLY applied to beverages with added sugar-all grocery or consumer food products are excluded.

Community Oversight Panel
• Provide Oversight & Annual Reporting
• Establish a Community Oversight Panel to report annually on the tax impact.
• Panel to include 7 community members and
provide recommendations on revenue use.

Fiscal Accountability
and Local Control

41.194
Economic Impact
$1.3 Million
To maintain essential services, the City is exploring a ballot measure that would add a tax of 2¢ per fluid ounce on the wholesale distribution of sugar-sweetened beverages (SSB).

Local Investments
• Parks and facilities that are accessible and safe
• Programs for children and youth
• Maintaining active recreation programs
• Facilities for seniors, children, and people of all ages Simple & Straight Forward Collection of tax
Local Funding for Our Community

41.195

41.196
Recommendation:

A Potential Measure for a Healthier Santa Cruz
Motion to:
1) Accept recommendations from the recent work of the City Council Sugar-Sweetened Beverage Ad Hoc Committee; 2) Adopt a resolution requesting that the November 5, 2024, General Election ballot include a general tax of two cents per fluid ounce on distributors of sugar-sweetened beverages that includes a Community Oversight Panel to transmit an annual report and make recommendations to the City Council; and
3) Support the measure for the purpose of authorizing arguments; directing the Mayor to designate up to three Councilmembers to identify authors and signers for the arguments in favor of this measure, working with members of the community if they so choose; directing the City Attorney to prepare the impartial analysis; and providing direction to the City Manager regarding the preparation of the fiscal analysis, as appropriate.

41.197
City Council

AGENDA REPORT
DATE: 06/04/2024
AGENDA OF: 06/25/2024
DEPARTMENT: City Manager
SUBJECT: City of Santa Cruz Homelessness Response Strategic Plan July 2024 – June 2027 (CM)
RECOMMENDATION: Motion to approve the City of Santa Cruz's Homelessness Response Strategic Plan, covering July 2024 – June 2027.

BACKGROUND: In March of 2022, the City of Santa Cruz adopted its first three-year Homeless Response Action Plan (HRAP). This comprehensive plan, fueled by $14 million onetime grant from the state of California, $4.0 million from American Rescue Plan Act (ARPA) funds, Community Development Block Grants, and the City’s General Fund, aimed to provide a holistic, coordinated, and action-oriented strategy. The HRAP outlined five key action areas to guide the City in balancing individual needs with community impacts.

Over the past three years, significant progress has been achieved, with the City fulfilling most of the outlined goals. The HRAP serves as a foundation for the new July 2024 – June 2027 Strategic Plan, which builds upon past accomplishments and sets a pathway for continued action in addressing homelessness.

Those accomplishments include the following:

Building Capacity and Partnerships: The City created a Homeless Response Team composed of

15.25 people spread over three departments. We have strengthened our partnerships with our regional partners including the County of Santa Cruz (County) and Community Based Organizations (CBOs) to create efficient and coordinated responses to the unhoused community.

The City has increased its community engagement efforts through community surveying, a dedicated website, social media, and 2 virtual town hall meetings.

Permanent Affordable and Supportive Housing: The City met its regional housing need requirement in 2023 and obtained the Pro-Housing designation from the state. The City has added 960 new affordable housing units. The City also completed the vision process for the Navigation Center on Coral Street.

Basic Support Services: The City opened the City Overlook Emergency Shelter program at the Armory to provide 135 safe sleeping sites. The 1220 River Street Transitional Shelter provides shelter to up to 30 people, and has been successful in placing people in to long-term stable housing. In partnership with the County and the City of Watsonville, a severe weather shelter

42.1 program was implemented during the worst of weather conditions and served 319 people. The Safe Parking Program offers 58 sites for oversized vehicles on a long-term and short-term basis.

The combination of these efforts has resulted in serving over 776 people, placing 121 people into long-term stable housing, and reconnecting 109 people with family and friends. Finally, significant investments were made at Housing Matters to update their hygiene services.

Care & Stewardship: The City successfully addressed several large illegal encampments, including San Lorenzo Park Benchlands (300 people), Sycamore Grove, and the Pogonip. City staff helped place those who wanted shelter into the City Overlook Program. The Homeless Response Field Crew Team removed 724 tons of debris from city parks, open spaces, and streets.

Community Safety. Through the collaborative efforts of the City’s Mental Health Liaisons, City Outreach Specialists, partnerships with organizations like Downtown Outreach Workers, and other community-based groups, individuals grappling with mental health challenges can access support services from non-law enforcement entities. This approach aims to provide assistance and connect individuals with the appropriate resources, fostering a more compassionate and effective response to the complex needs of the homeless population.

Through a collective effort with our regional partners including the County and CBOs, in 2023, according to the Point In Time Count, the County of Santa Cruz saw a decline in persons experiencing homelessness by 21%. More specifically, the City of Santa Cruz saw a 29% decline in homelessness.

The Strategic Plan (Plan) builds upon the foundation of past accomplishments and carries that work forward with a perspective informed by our past experiences. While some of the terminology has changed, and our values have been updated to include equity and our unwavering commitment remains steadfast. This Plan will guide the City’s homelessness response efforts over the next three years. While this Plan does not promise to end homelessness in the City, it will provide the community and staff with a strategy to help prioritize actionable steps within the City’s purview.

DISCUSSION: The Strategic Plan was informed by a robust community engagement program that included eight stakeholder sessions and an online community survey. Stakeholder meetings were held with people with lived experience of homelessness, community service providers, and city staff.

The Plan aligns where possible with the state and the County’s established goals and objectives to address homelessness. This alignment and coordination will help leverage current work being done at the state and county levels to be more efficient and effective at the city level.

This Plan is also in alignment with the 2023-2028 City’s Citywide Strategic Plan. The Citywide Strategic Plan establishes seven priority areas of focus for the City over the next five years. One of the seven is Homelessness Response: “Working with the County, move toward positive outcomes in homelessness response, safety and health, balancing the interests of persons who are unhoused, housed, and the business community.”
The Plan reflects our growth and experience over the past two and half years. Included now are a set of defined goals:
 Decrease Homelessness

42.2  Prevent Homelessness
 Increase Affordable Housing
 Reduce the Impacts of Encampments
 Protect the Environment
 Build Regional Partnerships and Capacity.

These goals are achievement targets. They provide direction and will serve as the guide towards our commitment: “In Santa Cruz, our homelessness response will strive to balance individuals needs with broad community impacts, spanning from prevention strategies to successful pathways to stable housing.”
The goals inform the five updated action areas:
1) Shelter, Care & Support
2) Building Capacity & Partnerships
3) Affordable & Supportive Housing
4) Community Safety
5) Environmental Stewardship
Within each action area, several strategies have been identified, supported by specific objectives.

Finally, ongoing, continuous measurement is important to determine progress and will enable the City to assess our progress towards our goals, identify areas for improvement, and make datadriven decisions.

FISCAL IMPACT: The Strategic Plan covers a three-year period, however the cost of implementing the first year of the Strategic Plan is approximately $9.6 million distributed across several departments (City Manager’s Office, Police Department, and Public Works). The Strategic Plan is solely funded by the City’s General Fund except for $750,000 remaining from the 2022 California State Grant. Those funds will be utilized towards the Coral Street Navigation Project ($500,000) and a storage program ($250,000). The City will continue to pursue additional revenue from the state and County to support the ongoing costs of the programs.

Prepared and Submitted By:

Lisa Murphy
Deputy City Manager
Approved By:

Matt Huffaker
City Manager
ATTACHMENTS:

1. HOMELESSNESS RESPONSE STRATEGIC PLAN 2024-2027.PDF

42.3 HOMELESSNESS

RESPONSE

STRATEGIC PLAN
July 2024 – June 2027

42.4 In March of 2022, the City
of Santa Cruz recognized
the changing landscape of
homelessness response and
the new role the City plays
in shelter provisions.

The City Council took the
important and necessary
step to create the first
Homelessness Response
Action Plan (HRAP) to guide
the City’s homelessness
response.

This updated Homelessness
Response Strategic Plan will
provide staff direction from
July 2024 through June
2027. During each year of
the plan, a yearly Action
Plan will be created to
implement the Strategic
Plan based on the changing
funding landscape.

The HRAP is the
foundation for the
Strategic Plan. The
Strategic Plan builds off
the work already
accomplished and carries
that work forward with
more informed
perspectives.

While some of the
terminology has changed,
and our values have been
updated, the commitment
has stayed the same. The
Strategic Plan will guide
the City through the next
three years of our
homelessness response.

The Strategic Plan does
not promise to end
homelessness in Santa
Cruz. Still, it provides the
community and staff with
a pathway to focus on
actions that fall within the
City’s responsibilities.

Long-term solutions
demand more affordable
housing and better
supportive services across
the County. These
necessitate investments
beyond what any single
entity can provide.

Without sustainable
funding, our current
programs are at risk. As a
community, we must
commit to resourcing this
ongoing endeavor.

Consistent, ample funding is
critical, as it will transition
individuals to homes,
thereby enhancing the
quality of life for everyone.

This is about safeguarding
human dignity, promoting
prosperity, and preserving
our environment.

HOMELESSNESS

RESPONSE

STRATEGIC PLAN

OVERVIEW
July 2024 – June 2027
Homelessness Response Strategic Plan 2

42.5 “To design effective programs and policies to
address homelessness, we need to understand
who is experiencing it, how they became
homeless, what their experiences are, and what is
preventing them from exiting homelessness.“
University of California San Francisco Benioff Homelessness and Housing Initiative The Strategic Plan aligns
with the State and County’s
identified goals and
objectives to address
homelessness.

This alignment and
coordination leverages
current work at the State
and County levels to be
more efficient and effective
within the City. The
Strategic Plan includes the
utilization of data from
Fiscal sustainability and
transparency
Homelessness response
Housing
Natural and built
infrastructure
Public safety and
community well-being
Strong business
communities and a
vibrant downtown
Thriving organization
City of Santa Cruz Citywide Strategic Plan
(2023 – 2028)
community surveys,
outreach to those with
lived experience, and
research from various
sources to inform our
goals and objectives.

The Strategic Plan also
aligns with the 2023–28
City of Santa Cruz
Citywide Strategic Plan,
where Homelessness
Response is listed as one
of the City’s seven focus
areas.

Homelessness Response Strategic Plan 3
Homelessness Response
Working with the County and community partners, the City moves toward positive outcomes in homelessness response, safety, and health, balancing the interests of persons who are unhoused and housed, and the business community.

42.6 Homelessness Response Strategic Plan 4

HOMELESSNESS STRATEGIC PLANNING

PROCESS OVERVIEW
This Strategic Plan was informed by a robust community engagement program that included eight stakeholder sessions and an online community survey. Stakeholder meetings were held with people who had lived experience of homelessness, community service providers, and City staff. At each session, the previous Homelessness Response Action Plan was reviewed, and stakeholders addressed issues, strategies, and future priorities.

Feedback from the Community
The Spring 2024 survey asked community
members to provide feedback on the City’s
current homelessness response actions. 690
community members completed the survey.

Survey results reflect a recognition of the
complex relationships between social,
economic, and environmental factors and a
desire for a comprehensive, multi-faceted
approach that prioritizes immediate needs and
long-term solutions.

Priorities for Community Members
Accessible parks and open space
Citizen safety
Business and economic concerns
Humanitarian concerns
Environmental concerns
Equitable enforcement of the law
Community well-being and quality of life
Clean neighborhoods and streets
Affordable housing and housing solutions
Service provision and support for the
unhoused
Feedback from People
Experiencing Homelessness
The City of Santa Cruz Homelessness
Response Team conducted surveys and focus
groups in November and December 2023
with individuals who are sheltered in Cityfunded programs and unsheltered individuals in encampments.

Priorities for People Experiencing
Homelessness
Expand shelter capacity with a diversity of
low-barrier shelter programs. Examples
include sober living environments, tiny
homes, indoor shelters, and women-only
options.

More day services to meet basic needs
Increased access to hygiene and health
services
Access to training and classes, including
financial literacy, job training, and legal
support
More assistance navigating the complex
network of regional social services (access
to care coordination, case management,
housing navigation, and more)

42.7 121
People Moved to More
Stable Housing
776
People Served in
Shelter & Safe
Parking
Homelessness Response Strategic Plan 5
Feedback from Service
Providers
The City’s Homelessness Response Team held
a focus group with local service providers to
solicit their input on strengths, weaknesses,
and gaps related to homeless services within
the City.

Priorities for Service Providers
Expand shelter capacity with a diversity of
shelter programs
Improve coordination between City
departments and community-based
services when resolving encampments
Increase the number of case managers in
the region
More supportive housing (sober living
environments and recuperative care)
Assistance with collaboration across
regional service providers (case
coordination meetings, shared trainings,
and more)
Feedback from City Staff
The City’s Homeless Response Team held a
workshop with internal City departments,
including the City Attorney’s Office, Police,
Fire, Planning, Economic Development, Parks
& Recreation, Library, Human Resources,
Water, and Public Works.

Priorities for City Staff
Staff Safety
More permanent supportive housing
Expand shelter capacity with a diversity of
shelter programs
Continue collaboration across City
departments
Increase collaboration with the County
Increase the number of case managers,
housing navigation, and outreach staff
Ongoing community education about the
City’s homelessness response efforts
960
New Affordable
Housing Units
2022 -2023 Accomplishments
29%
decrease
in unhoused people in
the City of Santa Cruz
since 2022

42.8 55 years old
77 years old
Homelessness at the National Level
Homelessness continues to be an urgent, life-and-death public health crisis across the nation.

Homelessness rose 12% nationally from January 2022 to January 2023. The rise was seen across all subgroups — families, older Americans, Veterans, youth, and young adults — and was driven by:

Rising housing costs and a dire shortage of deeply affordable housing units End of pandemic-era resources and protections
Lack of Congressional support for adequate funding to address the crisis Large numbers of recently arrived asylum seekers and other immigrants living in shelters and on the streets
Source: United States Interagency Council on Homelessness Annual Report for Fiscal Year 2023 Homelessness:

A Crisis at All Levels
Source: United States Interagency Council on Homelessness. https://www.usich.gov/guidance-reports-data/data-trends#homelessnessff Homelessness is Deadly
People who experience
homelessness die nearly 30
years earlier than the average
American and die at the
average age Americans
died in the year 1900.

People who experience homelessnesss Average American
Homelessness Response Strategic Plan 6

42.9 Nearly all of the study’s
participants stated that
housing costs posed the
most significant barrier to
regaining housing. Other
barriers include:

Lack of help from a
case manager
Finances
Logistical barriers
such as no phone,
transportation, or
documents
Criminal justice
involvement
Poor credit
The California Homeless
Housing Needs Assessment
(December 2022)
concluded that California
could solve homelessness
through investments of
$8.1 billion in housing,
shelter, and supportive
services every year for
the next 12 years. This is
equivalent to 2.7% of the
state budget.

California has the most people experiencing homelessness of any state in America.

Source: Department of Housing & Urban Development, Annual Homeless Assessment Report, March 2022 A comprehensive study on
homelessness conducted in
June 2023 by the UCSF
Benioff Homelessness and
Housing Initiative found
that the majority of adults in
California who experience
homelessness are:

Single
Over 25, with nearly
half over 50
Homeless in the
community where they
were last housed
Reporting significant
trauma in their lives
Reporting high levels of
mental health distress
and substance abuse
Reasons people became
homeless:

Losing their housing
(more than half were
previously renters)
Living in poverty
One in five enter
homelessness from an
institutional setting
Homelessness in California
The California Interagency
Council on Homelessness’s
Action Plan for Preventing
and Ending Homelessness in
California (September 2022)
focuses on prevention and
ultimately ending
homelessness in California.

Action areas:

Strengthening our
system to better
prevent and end
homelessness
Equitably addressing
the health, safety, and
services needs of
Californians
experiencing
homelessness
Expanding
communities’ capacity
to provide safe and
effective shelter and
interim housing.

Expanding and ensuring
equitable access to
permanent housing in
our communities
Preventing Californians
from experiencing the
crisis of homelessness
Homelessness Response Strategic Plan 7
Source: Towards a New Understanding: The California Statewide Study on People Experiencing Homelessness, UCSF Benioff Homelessness and Housing Initiative, June 2023

42.10 On any given night in California, more
than 161,000 people experience
homelessness — this equals 25% of all
Americans who are homeless.

California Interagency Council on Homelessness Action Plan for Preventing and Ending Homelessness in California, September 2022.

Collaboration at a regional
level is essential if we are to
be successful in reducing
homelessness in our
communities. The Housing
for Health Partnership
(H4HP) is the federally
designated continuum of care
(CoC) entity for Santa Cruz
County. H4HP coordinates
resources, programs, and
services that move us
forward in preventing and
ending homelessness in the
region.

H4HP is a collaborative body
that includes the County; the
cities of Santa Cruz, Capitola,
Watsonville, and Scotts
Valley; housing and service
providers; people with lived
experience of homelessness;
and other relevant
stakeholders.

Santa Cruz County: Housing for Health Partnership
The Countywide strategic
framework includes four core
goals:

Reduce the length of
time people experience
homelessness
Reduce the percentage of
people returning to
homelessness
Ensure our local data
captures information on
program outcomes and
community needs
Coordinate outreach and
access to services across
the region.

Source: Santa Cruz County Housing
for Health Partnership
8 In the past year, H4HP
received and distributed
approximately $6.0 million in
federal Housing and Urban
Development funding, over
$5.0 million in homeless
housing assistance,
prevention funding from the
State of California, and other
one-time grant funds.

In April 2024, the Santa Cruz
County Board of Supervisors
approved the 2024–27
Housing for a Healthy Santa
Cruz, A Strategic Framework
for Addressing Homelessness in
Santa Cruz County. This
strategic framework identifies
four high-level strategic
objectives:

Build a coalition
Prevent homelessness
Increase connections
Increase housing
affordability
Homelessness Response Strategic Plan 42.11
2011 2013 2015 2017 2019 2022 2023
2,771
3,536
1,964 2,249 2,167 2,299 1,804
Total Number of Persons Experiencing Homelessness in Santa Cruz Homelessness in the
City of Santa Cruz
2500
2000
1500
1000
500
0 970
1197
776
1028
860
1439
2019 2022 2023
City of Santa Cruz All other areas of the County
Homeless Population in City of Santa Cruz
Compared to Santa Cruz County City of Santa Cruz
The City of Santa Cruz has the highest
percentage of the homeless population in
the County — 57% of the homeless
population lives in the City of Santa Cruz.

In the 2023 PIT count, there was a 29%
drop in persons experiencing
homelessness in the City of Santa Cruz.

Homelessness Response Strategic Plan 9
According to the National Low Income Housing Coalition, the City of Santa Cruz was named one of the least affordable places to live in the United States in 2023. The necessary “housing wage” for a two-bedroom rental in Santa Cruz is $63.33 per hour, compared to the national 2023 housing wage of $28.58 per hour for a modest two-bedroom rental home. Research shows that communities can expect a more rapid increase in homelessness when people spend more than 32% of their income on rent.

Every two years, typically on a day in January, communities across the country conduct a comprehensive point in time (PIT) count of local homeless populations to measure the prevalence of homelessness. The 2023 Santa Cruz County PIT count shows a decline in persons experiencing homelessness by 21% County-wide and 29% Citywide.

42.12 2023 Survey on Homelessness in Santa Cruz
In the weeks that follow the street count, a more comprehensive survey of sheltered and unsheltered individuals is conducted to obtain more detailed information.

Causes of Homelessness in
Santa Cruz
Survey results revealed that the primary
causes of homelessness in our community are
job loss followed by substance use.

The majority of homeless in the County are
White (81%)
Male (71%)
Over 25 years old (65%)
75% of unsheltered survey respondents
indicated they had lived in Santa Cruz County
before losing their housing.

Support Needed to Secure
Permanent Housing
When asked what kind of support
respondents needed to obtain permanent
housing, rental assistance was the most
common (77%) answer. 60% reported that an
increase in the availability of affordable
housing would support their ability to obtain
permanent housing.

Federal, State, and Local
Partnerships
The City of Santa Cruz cannot solve
homelessness alone. We need partners at the
County level to provide much needed mental,
behavioral, or physical health services. Cities
are not responsible for these types of health
and human services.

In recent years, cities across the country have
had to develop and implement programs and
services to address the growing crisis of
homelessness in our communities. Temporary
shelter is crucial to address the immediate
needs of people living in our parks, open
spaces, doorways, and streets. While we make
progress on building permanent supportive
housing, people need shelter now.

The City is one piece of the puzzle to solve
homelessness. To eliminate homelessness,
ongoing collaboration with state and federal
governments is needed to achieve stable,
longer-term funding.

Homelessness Response Strategic Plan
Primary Conditions that
Led to Homelessness
35%

LOST JOB
24%

SUBSTANCE
USE
19%

EVICTION
13%

DIVORCE/

BREAKUP
11%

CONFLICT
WITH

FAMILY OR
FRIEND
13%

FAMILY OR

DOMESTIC

VIOLENCE
10 Source: 2023 Point in Time Count Survey 42.13
City of Santa Cruz History of
Homelessness Response
Over the past seven years, the City has taken the following actions regarding homelessness response:

In addition, the City fostered partnerships with local service providers, such as Downtown Outreach Workers (1994) and the Homeless Outreach, Proactive Engagement and Services (HOPES) program (2014).
2018
The first City-funded emergency shelter opens at 1220 River Street 2019
The Community Advisory Committee on Homelessness established to support City policy on homelessness response.
2020
City hires first Homeless Response Manager.
2021
City adopts ordinances for oversized vehicles and camping services and standards.

City receives a $14 million grant for homelessness response from the State of California and combines this with $4 million from ARPA.
2022
City creates Homelessness Response Division and first three-year Homelessness Response Action Plan.

City hires first Homeless Response Field Crew Team, including Outreach Specialists.

Police Department assigns two dedicated Community Service Officers to the team.

City opens a 135-person shelter called the City Overlook at the Armory.

City opens 1220 River Street Transitional Community Camp.

City opens long-term, overnight-only, and emergency safe parking programs. 2023
City hires a legislative lobby firm to advocate for state and federal funding.

City receives the Pro-Housing Designation from the state in recognition of the City’s efforts to build affordable housing and meet the state Regional Housing Needs Allocation.
2024
City dedicates $9.6 million from the general fund to homelessness response programs.

City Council adopts three-year Homelessness Response Strategic Plan.

City receives $4.0 million Encampment Resolution Grant.

Homelessness Response Strategic Plan 11 42.14
Building on the success of
the 2022 Homelessness
Response Action Plan, the
2024 Homelessness
Response Strategic Plan
represents a significant step
forward in the City’s efforts
to tackle homelessness.

Developed collaboratively, it
includes input from
nonprofit providers, staff,
and community members,
including individuals with
lived experience. The plan is
a blueprint for the City of
Santa Cruz’s homelessness
response over the next
three years.

This Strategic Plan
leverages insights, data,
and priorities gathered
from stakeholders, the
annual PIT count, current
City programs, the
Citywide Strategic Plan,
and Santa Cruz County’s
Strategic Framework for
Addressing Homelessness.

With clear policy goals
and actionable strategies,
the Strategic Plan aligns
the work of the City with
homeless service
providers and Santa Cruz
County’s efforts.

The result is an enhanced,
collaborative, and
coordinated response to
homelessness.

The City’s values are
updated to explicitly include
equity as an important
aspect of our work.

Our community has a
substantial need for shelter,
and we must all work
together to focus on what
matters most — compassion
and care.

Homelessness Response
Strategic Plan
2024 – 2027

OUR COMMITMENT
In Santa Cruz, our homelessness response will strive to balance individual needs with broad community impacts, spanning from prevention strategies to successful pathways to stable housing.

Health
Safety
Collaboration
Trasparency
Economic Vitality
Fiscal Responsibility
Equity
Environmental Stewardship
VALUES
Our City’s response to homelessness centers on:
12 42.15
Decrease Homelessness: reduce the number of people who are unsheltered and the total number of people experiencing homelessness.

Prevent homelessness: reduce the number of people who fall into homelessness.

Increase affordable housing units: meet and/or exceed RHNA goals.

Reduce the impacts of encampments: protect environmentally sensitive areas and ensure equitable access to parks and open spaces for everyone in the community.

Build regional capacity and partnerships to resolve homelessness: build strong partnerships across all sectors to leverage resources, share expertise, and effectively coordinate efforts.

ACTION AREAS
Homelessness Response Strategic Plan
GOALS
Homelessness Response Strategic Plan 13 42.16
Homelessness Response Strategic Plan 14

ACTION AREAS & STRATEGIES
Building Capacity & Partnerships
An organizational response to homelessness and housing instability, including greater internal coordination and alignment of services.

Expanding our community’s overall capacity and effectiveness.

Expanded legislative outreach and public engagement.

Maintain and expand
organizational capacity
and internal collaboration
Create and implement an annual action plan documenting
the progress of the Strategic Plan, identify annual funding resources, and refine the Strategic Plan as necessary.

Continue to fund a dedicated staff for the Homelessness Response Program.

Conduct weekly internal coordination meetings between
City departments.

Support community-based organizations (CBO’s) to
create more transitional employment programs, including expansion of Downtown Streets Team.

Continue to partner with CBOs to increase available case management for people experiencing homelessness.

Conduct quarterly meetings with our CBOs.

Establish partnerships with faith-based organizations.

Continue regular City-County Collaborative meetings.

Support and utilize data to enhance effective
coordination.

Partner with the County to secure funding for emergency shelter, severe weather shelter and a navigation center.

Formalize roles and responsibilities with the County via a MOU.

Collaborate with
community-based and
faith-based organizations
to provide effective and
efficient service delivery
Work in alignment with
the County to increase
our effectiveness at
reducing homelessness
Continued on next page

42.17 ACTION AREAS & STRATEGIES
Building Capacity & Partnerships
Increase community
engagement and
education on the City’s
homelessness activities
and programs
Develop annual targeted state and federal legislative asks for policy reform and funding related to substance use
disorder, mental health and homelessness response.

Work with legislative groups (League of Cal Cities) to
build a statewide coalition of municipalities for legislative changes and funding.

Identify opportunities to influence & support legislation that aligns with Santa Cruz’s homelessness strategies.

Continue regular updates to staff, council, and
community partners.

Post and share on city channels (social media, website, email newsletters, webinars, events).

Develop timely and relevant communications for at-risk
community members and unhoused individuals to ensure
they know how to access services and programs.

Conduct an annual survey to measure awareness of city
services, service gaps, experiences, and opinions.

Continue to pursue state and federal grants to support
programs, including the 2024 Encampment Resolution
Grant of $4.0 million. For that grant, implement programs and services related to the grant in partnership with
Housing Matters and the County.

Work with our County partners to secure funding for
emergency shelter programs.

Continue to commit general fund dollars to support
ongoing programs.

Assess existing programs for efficient use of funds.

Establish sustainable
funding sources
Continue pursuing
legislative action to
obtain support from
state and federal levels
15 42.18
Homelessness Response Strategic Plan 16

ACTION AREAS & STRATEGIES
Affordable & Supportive Housing
Santa Cruz is a leader in proactive and innovative approaches to expanding affordable and supportive housing. Affordability and availability are two of the most significant contributors to our region’s homelessness crisis. These actions will advance the City’s longstanding commitment to expand housing opportunities in our community.

Retain, protect and
increase the supply of
housing
Support the development of affordable housing projects.

Identify ongoing funding for supportive housing projects.

Issue an RFP to identify and contract with a design firm.

Work with the County departments to develop the
project.

Apply for grant funding to develop the project.

Evaluate and enact local housing policies to promote
housing development, particularly additional low and
very-low income housing.

Advocate state & federal legislation for housing funding.

Monitor state legislation and take positions on bills to further housing production statewide.

Obtain funding to support local eviction prevention,
rental assistance, legal assistance, and tenant education.

Support efforts for housing stabilization.

Support the development of affordable housing projects.

Increase access to
housing navigation and
essential services by
continuing to develop a
vision for the Coral
Street area including a
navigation center
Expand the City’s
capacity to identify and
utilize policy changes to
increase housing
Increase homelessness
prevention efforts

42.19 Homelessness Response Strategic Plan 17

ACTION AREAS & STRATEGIES
Address community
impacts and
neighborhood concerns
from encampments and
litter
Resolve encampments quickly as shelter space allows.

Employ contractors to provide services for refuse
removal and restoration.

Quickly remove abandoned refuse to mitigate the
potential for environmental damage.

Continue to work with City departments to implement
environmental design options and deter re-encampment
in open spaces.

Partner with community groups for restoration of
affected habitats.

Maintain City parks and open spaces for community-wide
use.

Continue to work towards the goal of establishing free or extremely low-cost waste disposal site within the City, and keep the Council updated on progress.

Expand the Homelessness Response Field Crew Team’s
ability to regularly remove abandoned litter by providing additional support through contractors, additional
equipment, and supplies.

Conduct assessment and outreach to encampments
affecting the City’s open spaces in preparation for
wildfire and flood season.

Reduce illegal dumping
of hazardous waste &
debris
Environmental Stewardship
Protect our environment by reducing the impacts of illegal disposal of trash & debris. Address community impacts and neighborhood concerns from illegal encampments.

Wildfire and flood
protection

42.20 Utilize HMIS data to identify potential equity issues in both rates of homelessness and access to services.

Include the voices of those with lived experience in
design of programs and services.

Identify ongoing funding for permanent supportive
housing projects.

Continue to offer emergency shelter programs:

City Overlook at the Armory
1220 River Street Transitional Community
Severe Weather Shelter Program
Continue to offer safe parking programs:

Long-term safe parking
Overnight-only safe parking
Partner to expand emergency shelter capacity, womenonly shelters, tiny homes, and sober living environments.

Provide storage program for persons experiencing
homelessness

ACTION AREAS & STRATEGIES
Shelter, Care, and Support
Individuals experiencing homelessness often have complex needs, including mental health issues, substance abuse disorders, and chronic health conditions. Comprehensive support services are essential to help them stabilize their lives, in addition to providing shelter until permanent housing solutions become available.

Ensure equity & access
Reduce the number of
unsheltered individuals
by providing emergency
shelter and supporting
programs
18 Continued on next page

42.21 ACTION AREAS & STRATEGIES
Shelter, Care, and
Support
Collaborate with the County to expand substance abuse
and mental health treatment services.

Develop partnerships with healthcare providers to reduce exits from the hospital system to homelessness (Janus,
HPHP, and Dignity Health).

Work with community partners to provide behavioral.
health and substance abuse treatment services.

Evaluate and enact local housing policies to promote
housing development, particularly additional low and
very-low income housing.

Advocate state & federal legislation for housing funding.

Monitor state legislation and take positions on bills to further housing production statewide.

Connect people to
behavioral and medical
services
Improve assistance to
people in navigating the
complex network of
social services
19 42.22

ACTION AREAS & STRATEGIES
Community Safety
Balancing public safety with addressing homelessness is a complex challenge that requires careful consideration including legal, ethical, and practical concerns. While being homeless itself is not a crime, people experiencing homelessness at times engage in unlawful behavior which requires the response of law enforcement.

Equitable enforcement of
criminal behavior
Collaborate between SCPD, Homeless Response Field
Crew, and Outreach Teams to provide equitable &
compassionate response.

Work with the district attorney to successfully prosecute criminal behavior.

Work with the County to enhance diversion programs for
repeat offenders.

Implement the Mobile Crisis Response Team in
collaboration with the County.

Continue to fund the Mental Health Liaisons positions in collaboration with the County.

Utilize City outreach specialists to assist officers with individuals who need support.

Reduce the number of calls for service by the Santa Cruz Fire Department by adding an EMT to the Mobile Crisis
Response team.

Decrease number of calls
to law enforcement from
individuals experiencing
mental health crises
Provide access to basic
health needs on the
street.

Homelessness Response Strategic Plan 20 42.23
Preventing and Resolving Homelessness
How will we know that our strategic plan is working? The following data points will help us remain focused on our commitment to balancing individual needs with broad community impacts, from prevention strategies to successful pathways toward stable housing.

Decrease Homelessness: reduce the number of people who are unsheltered and the total number of people experiencing homelessness.
# of people who have moved into more stable housing after participating in City programs # of people served through City programs
Point-In-Time Count (PIT Count)
Homeless Management Information System (HMIS) Data
Prevent homelessness: reduce the number of people who fall into homelessness.

PIT Count
# of people served by the City’s eviction prevention program Increase affordable housing units: meet and/or exceed RHNA goals. # of transitional, permanent supportive, and below-market-rate housing units that are preserved or produced
Reduce the impacts of encampments: protect environmentally sensitive areas and ensure equitable access to parks and open spaces for everyone in the community.

Reduction in # of calls for service
Amount of refuse removed from encampments
Community engagement and annual survey
Build regional capacity and partnerships to resolve homelessness: build strong partnerships across all sectors to leverage resources, share expertise, and effectively coordinate efforts.

Create opportunities to partner on funding, service connection, and outreach.

Measuring Our Success
Homelessness Response Strategic Plan 21 42.24
City of Santa Cruz
Homeless Response Strategic Plan
June 25, 2024
1 42.25
Agenda
• Introduction
• Planning Process
• Homelessness: A Crisis at All
Levels
• Strategic Plan 2024-2027
• Measuring Our Success
2 42.26
Big
Wins

42.27 More
Big
Wins

42.28 HOMELESSNESS RESPONSE STRATEGIC PLAN
July 2024 – June 2027
Roadmap for the next three years
Builds off the work that has already been accomplished in the Homelessness Response Action Plan
The Plan implements one of the seven Citywide Strategic Plan Focus Areas: “Homelessness” Annual update to the community on the status of the Strategic Plan Plan is in alignment with State and County Plans

42.29 HOMELESSNESS

STRATEGIC PLANNING

PROCESS
Stakeholder Engagement and Feedback:
• City Staff
• Service Providers
• People Experiencing Homelessness
• Community Members
• Businesses

42.30 Priorities for City Staff
• Staff Safety
• More permanent supportive housing
• Expand shelter capacity with a diversity of shelter
programs
• Continue collaboration across City departments
• Increase participation from the County
• Increase number of case managers, housing
navigation, and outreach staff
• Ongoing community education about City’s
homelessness response efforts

42.31 Priorities for Service Providers
• Expand shelter capacity with a diversity of shelter
programs
• Improve communication between City departments
and community-based services when resolving
encampments
• Increase number of case managers in the region
• More supportive housing
• Assistance with collaboration across regional service providers

42.32 Priorities for People with Lived
Experience
• Expand shelter capacity with a diversity of lowbarrier shelter programs • More ‘day services’ to meet basic needs
• Better access to hygiene and health services
• Access to training and classes including financial
literacy, job training, and legal support
• More assistance navigating the complex network of
regional social services

42.33 Priorities for Community Members
• Accessible parks and open space
• Citizen safety
• Business and economic concerns
•Humanitarian concerns
• Environmental concerns
• Equitable enforcement of the law
• Community well-being and quality of life
• Clean neighborhoods and streets
• Affordable housing and housing solutions
• Service provision and support for the unhoused.

42.34 HOMELESSNESS

A CRISIS AT ALL
LEVELS
National Level: Homelessness rose 12%
nationally from January 2022 to January
2023
State Level: California has the most
people experiencing homelessness of any
state in America. 161,000 people in
California are homeless.

County: 40% are experiencing
homelessness for the first time.

City of Santa Cruz: 57% of the Counties
homeless population lives in the City of
Santa Cruz.

42.35 Homelessness in the City of Santa Cruz
In 2023 City of Santa Cruz was named one of
the least affordable place to live in the
United States.
57% of the Homeless
Population in the County
lives in the City of Santa
Cruz
City: 2023 a decline
in homelessness by
29% from 2022.
2024 PIT
Complete
Data Not
Available

42.36 Causes of Homelessness
in Santa Cruz County
2023 PIT Survey
The majority of homeless in the
County are:
• White (81%)
•Male (71%)
• Over 25 years old (65%)

42.37 Homelessness in
County of Santa
Cruz
• 2023 PIT Survey – Self Reported Health conditions that may affect housing stability of those experiencing homelessness

42.38 Alignment of
Strategic Plan
Goals
City Strategic Plan Goals County Objectives
Decrease Homelessness Increase Housing
affordability
Prevention of Homelessness Prevent Homelessness
Reducing the Impacts of
encampments
Building regional capacity Build a coalition

42.39 City and County Collaboration
Lobbying efforts
Severe Weather shelter
Coral Street Navigation Center
Encampment Resolution Grant
Bi-weekly coordination meetings with staff
Housing For Health Policy Board (COC)
Outreach staff support during encampment closures and service connection

42.40 HOMELESSNESS

RESPONSE

STRATEGIC PLAN
2024-2027

OVERVIEW

COMMITMENT
VALUES
GOALS

ACTION AREAS

STRATEGIES

42.41 Homelessness Response
Strategic Plan 2024-2027

42.42 STRATEGIC PLAN
GOALS - New
Decrease Homelessness
Prevent Homelessness
Increase Affordable Housing Units
Reduce the Impacts of Encampments and Protect
the Environment
Building Regional Capacity & Partnerships

42.43 ACTION AREAS - Updated

42.44 Building Capacity &
Partnerships
An organizational response to homelessness and
housing instability, including greater internal
coordination and alignment of services. Expanding
our community’s overall capacity and effectiveness.

Expanded legislative outreach and public
engagement.

STRATEGIES:
• Organizational capacity & Internal collaboration
• Collaborate with community-based and faith-based
organizations to grow our collective capacity.
• Work in alignment with the County
• Legislative Advocacy
• Community engagement
• Establish sustainable funding sources

42.45 Affordable &
Supportive Housing
Santa Cruz is a leader in proactive and innovative
approaches to expanding affordable and supportive
housing. Affordability and availability are two of the
most significant contributors to our region’s
homelessness crisis. These actions will advance the
City’s longstanding commitment to expand housing
opportunities in our community.

STRATEGIES
• Retain, Protect and increase the supply of housing
• Increase access to housing navigation & essential
services by developing a navigation center
• Homelessness prevention efforts

42.46 Environmental
Stewardship
Protect our environment by reducing the
impacts of illegal disposal of trash & debris.

Address community impacts and
neighborhood concerns from illegal
encampments.

STRATEGIES:
• Address community impacts and neighborhood
concerns from encampments and litter
• Reduce illegal dumping of hazardous waste &
debris
• Wildfire and flood protection

42.47 Shelter, Care, and
Support
Individuals experiencing homelessness often have
complex needs, including mental health issues,
substance abuse disorders, and chronic health
conditions. Comprehensive support services are
essential to help them stabilize their lives, in addition to providing shelter until permanent housing solutions
become available.

STRATEGIES
• Ensure equity and access to all services
• Reduce the number of unsheltered individuals by
providing emergency shelter and supporting
programs:
• Armory Overlook
• 1220 River Street
• Safe Parking Programs
• Connect people to behavioral and medical services
• Improve assistance to people in navigating the
complex network of social services

42.48 Community Safety
Balancing public safety with addressing
homelessness is a complex challenge that requires
careful consideration including legal, ethical, and
practical concerns. While being homeless itself is
not a crime, people experiencing homelessness at
times engage in unlawful behavior which requires
the response of law enforcement

STRATEGIES
• Equitable enforcement of criminal behavior
• Decrease number of calls to law
enforcement from individuals experiencing
mental health crisis
• Provide access to basic health needs on the
street.

42.49 Measuring our Success
Decrease Homelessness
- # of people into more stable housing
- PIT Count
- HMIS Data
- # of people served through City programs
Prevent Homelessness
- PIT Count
- Number of people served by eviction
prevention program
Increase affordable housing units
- # of transitional, permanent supportive,
and below market rate housing units that
are preserved, or produced
Reduce the impacts of
encampments.
- Reduction in # of calls for service
- Amount of refuse removed from
encampments
- Annual survey and community Outreach
Build regional capacity &
partnerships
- Create opportunities to partner on
funding, service connection, and outreach

42.50 Questions or
Comments

42.51 27
City Council

AGENDA REPORT
DATE: 06/05/2024
AGENDA OF: 06/25/2024
DEPARTMENT: City Manager
SUBJECT: Monterey Bay Area Regional Climate Project Working Group (CM) RECOMMENDATION: Motion to:
1) Accept the presentation on the activities of the Monterey Bay Area Regional Climate Project Working Group (RCPWG); and
2) Adopt a resolution affirming the City Council’s intention to commit to funding the City of Santa Cruz’s contribution for the RCPWG for three (3) additional years (through FY 2027), if feasible given the status of the General Fund.

BACKGROUND: Climate change is a priority issue for organizations across the Monterey Bay region. A focused and organized approach to accessing historic California and federal funding and resources is required to bring the region together to collectively achieve equitable and resilient outcomes. Access to large scale transformative grant opportunities has the potential to accelerate implementation of climate change mitigation and adaptation projects and programs across the three-county region. The Monterey Bay Area Regional Climate Project Working Group (RCPWG) was formed in 2021 to work together to access transformative funding opportunities to achieve the region’s resilience goals. RCPWG applied for over $32M in grants since 2022 and has brought in nearly $3M to the region to date. The City is a founding member of the RCPWG and the Sustainability and Resiliency Officer serves as vice-chair.

The mission of the RCPWG is to collaborate among groups and organizations in the Monterey Bay Area region, including Santa Cruz, San Benito, and Monterey Counties, to develop, prioritize, secure funding for, and effectively and equitably advocate for and implement regionally beneficial climate mitigation and adaptation projects and programs. RCPWG membership is currently composed of staff from Monterey, Santa Cruz and San Benito Counties, and the Cities of Santa Cruz and Watsonville, as well as the organizations that serve as advisors, including Ecology Action and the Association of Monterey Bay Area Governments (AMBAG).

The City of Capitola is joining the RCPWG as a dues-paying member in FY 2025. Other jurisdictions are participating as observers to consider the value of the collaboration and its membership.

The RCPWG established interim governance and adopted an interim charter in February 2023 (see Attachment: Recommendations for Advancing Equitable RCPWG Decision-making for Climate Investments). The interim charter allowed for the group to begin pursuing funding for

43.1 the region, while continuing to build the membership and build relationships with social and environmental justice Community-Based Organizations (CBOs). Following adoption of the charter, RCPWG members elected a Chair and Vice-Chair as the leadership team.

RCPWG Activities
Members of the RCPWG benefit from learning about grant opportunities, jointly developing competitive grant proposals, and accessing an established network of consulting and CBO partners that can lead and contribute to the development of grants and implementation of projects that address climate change in the region.

The RCPWG Strategy Team meetings are conducted to discuss RCPWG administration and upcoming grant opportunities. Additionally, RCPWG leadership (currently a Chair and ViceChair) meet with the Consulting Team, as needed, to discuss consultant contract obligations, plan for upcoming meetings, and the status of securing new and existing grant opportunities.

The primary activities of RCPWG members include:
 Share knowledge of grant opportunities and project updates across jurisdictions,  Design roles in grant proposals,
 Scope projects for grant proposals,
 Participate in grant funded roles and projects,
 Evaluate grant proposal preparation and project execution process,  Attend one call every six weeks, or as needed, to discuss RCPWG operations and grant opportunities,
 Hire and manage consultants,
 Collectively decide which grants to pursue and how to pursue them, and  Support ongoing discussions of governance for RCPWG and equity considerations.

As described in the charter, the RCPWG members use consent-based decision making with respect to:
 What grants the RCPWG pursues,
 Which advisors to invite to participate in discussions (including regional agencies, nonprofit 501(c)3 organizations, or tribal organizations/governments),  Subcommittee formation,
 Membership and Leadership, and
 Dues structure.

DISCUSSION: With the financial support of the Urban Sustainability Directors Network (USDN) through an Emergent Learning Fund grant, RCPWG members engaged environmental justice (EJ) groups and CBOs, including members of the Monterey Bay Area Climate Justice Collaborative (MBCJC), to participate in a project entitled, Advancing Equitable, Shared Governance for Monterey Bay Regional Climate Investment Decision-making.” In this project, participants worked to define their roles and relationships with respect to the RCPWG’s project development and decision-making processes. By incorporating CBO voices into the collaborative governance structure, the RCPWG will develop more inclusive and competitive grant proposals, which in turn leads to more resources for equitable climate projects and programs in the region.

43.2 The intended goals of this project, through these three workshops, were to:

1. Secure commitments for ongoing funding of the RCPWG’s work, including compensation for EJ and CBO participation,

2. Continue to build trust and relationships with CBO and EJ groups, and

3. Cultivate elected and executive champions.

Project Outcomes
The RCPWG held three workshops between February and May 2024 with elected, city and county staff members of the MBCJC and other CBOs and other observing city and county staff.

Through the three workshops, the RCPWG listened to CBOs and prepared and refined guidance around equitable engagement and decision-making. The recommendations that came out of this project are focused on the operation and implementation practices of the RCPWG. However, individual jurisdictions may use the recommendations that came out of this project to inform internal practices for their respective climate resilience projects or programs.

RCPWG Commitments Moving Forward
Based on the input received during the three workshops, the RCPWG members commit to the following:

1. RCPWG will include interested EJ groups and CBOs on the RCPWG listserv:

Interested EJ groups and CBOs include individuals or organizations who want to be informed of meeting dates and upcoming grant opportunities shared across the region.

Individuals can determine if they are interested in joining the meetings based on the agendas and their interest in certain upcoming grants.

2. RCPWG will invite interested EJ groups and CBOs to participate in RCPWG activities as RCPWG Advisors: Consistent with the existing charter, EJ groups and CBOs will be invited to advise on RCPWG activities, based on the needs of their communities, in an ad-hoc advisory capacity. RCPWG activities are outlined above.

3. RCPWG will invite EJ groups and CBOs to sit on and advise RCPWG subcommittees or grant-specific work groups: Subcommittees meet infrequently, on an as-needed basis, on specific grant opportunities. For example, in 2022-2023, there were two subcommittees formed to discuss specific current grant opportunities: the Transportation and Building Electrification Subcommittees. Using the listserv to inform and gauge interest in specific grant opportunities, EJ groups and CBOs will be invited into grant preparation working groups. If grants are awarded, EJ groups and CBOs will be invited to participate in subcommittee and working groups that support project implementation.

4. RCPWG will compensate interested individuals, EJ groups, and CBOs that request funding for meeting attendance, pending funding availability: There will be limited compensation, and the RCPWG will continue to work with EJ groups and CBOs on how to equitably allocate funding based on need. Compensation for participation of EJ groups and CBOs is a priority for the RCPWG moving forward, acknowledging that there may be some limitations on the use of public funds for some jurisdictions.

5. EJ groups and CBOs are eligible to serve as funded partners in grant implementation:

As part of the grant scoping discussions, interested groups may be budgeted into grant applications to serve as funded implementation partners or outreach partners.

However, they are not expected to serve in this capacity.

6. RCPWG will work towards implementing recommendations for leading practices for equitable engagement: Through the three-workshop series, workshop participants

43.3 identified leading practices and policies for the RCPWG to consider adopting to better enable EJ group and CBO participation in identifying and securing equitable climate funding. The recommendations are included in the project deliverable, Attachment: Recommendations for Advancing Equitable RCPWG Decision-making for Climate Investments

7. RCWPG will establish a timeline to integrate leading practices for engaging EJ groups and CBOs in RCPWG activities. The timeline will include when the RCPWG members will next evaluate the governance structure with the CBO advisors based on the priorities of the group.

8. RCPWG will explore additional opportunities for EJ group and CBO engagement as more funding becomes available for EJ group and CBO compensation. This may include identifying a single interested representative who has the capacity to join all RCPWG meetings on behalf of other EJ groups and CBOs. Workshop participants also suggested RCPWG consider identifying a dedicated member of the RCPWG to be the liaison between the RCPWG members and the EJ groups and CBOs representatives.

9. RCPWG members will expand RCPWG membership to better represent the tricounty region: RCPWG members will continue engaging interested city staff from the Cities of Salinas and Gonzales, and other city and county staff in the region to expand the membership of the RCPWG in 2024 and beyond.

The Sustainability and Resiliency Officer will continue to keep the climate advisory bodies including the Health in All Policies City Council Committee advised on progress of the RCPWG and strategize with these bodies to increase RCPWG’s inclusion, capacity, and funding success.

FISCAL IMPACT: The Urban Sustainability Directors Network (USDN) Emergent Learning Fund grant was secured by RCPWG member jurisdictions in summer 2023. The grant was $15,000 dedicated to advancing equitable, shared governance for Monterey Bay regional climate investment decision-making with additional funds from the RCPWG supplementing the USDN grant.

The City of Santa Cruz budgets $20,000 from the General Fund each year to contribute to the RCPWG, pooling funds with other jurisdictions. Adoption of this resolution sets the intention that the City will continue to budget this $20,000 annual contribution from FY 2025 through FY 2027, if feasible given the status of the General Fund. Each fiscal year, the RCPWG collects $100,000 in total from member jurisdictions that is used for grant administration, writing and support. The RCPWG acknowledges city leadership’s recognition of how these funds act as multipliers, leveraged for greater success in obtaining funding and driving broader climate impact.

Prepared By:

Tiffany Wise-West
Sustainability and Resiliency
Officer
Submitted By:

Laura Schmidt
Assistant City Manager
Approved By:

Matt Huffaker
City Manager

43.4 ATTACHMENTS:

1. RESOLUTION.DOCX

2. RECOMMENDATIONS FOR ADVANCING EQUITABLE RCPWG DECISION-MAKING FOR CLIMATE INVESTMENTS.PDF

43.5 RESOLUTION NO. NS-XX,XXX

RESOLUTION OF THE CITY COUNCIL OF THE CITY OF SANTA CRUZ AFFIRMING ITS INTENTION TO FUND THE CITY’S CONTRIBUTION TO THE MONTEREY BAY

REGIONAL CLIMATE PROJECT WORKING GROUP FOR THREE ADDITIONAL YEARS THROUGH FISCAL YEAR 2027
WHEREAS, the United States Federal government allocated unprecedented funding for climate change programs and projects through the American Rescue Plan (2021), the Infrastructure Investment and Jobs Act (2021), and the Inflation Reduction Act (2022); and WHEREAS, the State of California has allocated unprecedented funding for climate work through the California Climate Investments (i.e., the cap and trade program), budget allocations, and funding provided through the California Energy Commission and other state agencies; and WHEREAS, the Monterey Bay Area Regional Climate Project Working Group (RCPWG) was formed in 2021 to work together to access these transformative funding opportunities to achieve the region’s emissions and resilience goals; and WHEREAS, each RCPWG member contributes annually to the group’s fiscal sponsor, pooling funds to hire grant writers, strategists, and equity advisors; and WHEREAS, the RCPWG has set the stage for the region’s just transition by pursuing over $32 million in grant funding, developing and carrying out project concepts, strengthening connections with community-based organizations and the regional climate justice collaborative and inviting elected and executive participation in recent RCPWG activities; and WHEREAS, the City of Santa Cruz City Council affirms its commitment to the value and power of regional collaboration for equitable climate solutions; NOW, THEREFORE, BE IT RESOLVED by the City Council of the City of Santa Cruz as follows:

The City Council of the City of Santa Cruz affirms its intention to commit to funding the City’s contribution to the RCPWG annually for three additional years through fiscal year 2027 (if feasible given the status of the General Fund).

PASSED AND ADOPTED this 25th day of June, 2024 by the following vote:

AYES:

NOES:

ABSENT:

DISQUALIFIED:

43.6 RESOLUTION NO. NS-XX,XXX
2 APPROVED: ______________________________
Fred Keeley, Mayor
ATTEST: _________________________________
Bonnie Bush, City Clerk Administrator

43.7 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Recommendations for
Advancing Equitable RCPWG
Decision-making for Climate
Investments
May 2024 Prepared for the RCPWG by:

43.8 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Table of Contents
Summary 3
Project Overview 3
Recommendations for Embedding CBOs into the Operations and Decision-making Processes of RCPWG 4
Recommendations for RCPWG Operations 5
Continue to Strengthen Relationships and Partner with CBOs 5 Foster Accessible and Inclusive Communications 6
Support Accessible and Inclusive Meetings 7
Farallon Strategies’ Additional Recommendations 9
Recommendations for equity engagement design during grant proposal process and post-awarded grants 10
Appendix 12
Appendix A: RCPWG Acronyms 12
Appendix B: RCPWG Interim Charter 12
The Challenge and Opportunity 12
RCPWG Mission 12
Membership 13
Leadership 13
Decision-Making 13
Dues and Stipends 13
Sub-Committees 14
Meetings 14
Appendix C: RCPWG Activities 14
Appendix D: Workshop Materials 15
Workshop Participants 15
Workshop 1 16
Workshop 2 20
Workshop 3 28
| 2

43.9 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Summary
The Monterey Bay Area Regional Climate Project Working Group (RCPWG) was a concept that emerged from the ground up in 2021 and 2022 in response to the need to coordinate on historic funding opportunities for work on climate change that could be regionally impactful. The RCPWG first focused on establishing interim governance quickly and adopted an interim charter in February 2023 (see appendix) to allow the group to quickly begin pursuing significant funding for the region.

Following adoption of the charter, RCPWG members elected a Chair and Vice-Chair as the leadership team. With funding from the Urban Sustainability Directors Network (USDN), RCPWG members are engaging environmental justice (EJ) groups and community-based organizations (CBO) to help define their roles and relationships with respect to the RCPWG’s project development and decision-making processes.

This document is a summary of the leading best practices identified by RCPWG members and advisors, elected officials, and CBOs and EJ groups developed during a series of workshops. The recommended practices are focused on RCPWG operations and decision-making, and recommendations for equity engagement design during grant proposal process and post-awarded grants.

Project Overview
RCPWG membership is currently composed of staff from Monterey, Santa Cruz and San Benito Counties, and the Cities of Santa Cruz and Watsonville, as well as the advisors Ecology Action and the Association of Monterey Bay Area Governments (AMBAG). The RCPWG aims to expand membership in 2024 to include staff from more jurisdictions in the Monterey Bay Area, as well as environmental justice (EJ) groups and community-based organizations (CBOs).

Though CBOs and EJ groups were involved in the formation stages of the RCPWG, they were not originally included in the charter. The startup pace of the RCPWG precluded fully building out governance and the RCPWG wanted to be intentional about building equity across workstreams. Through the financial support of the Urban Sustainability Directors Network (USDN), RCPWG members are now engaging CBOs and EJ groups, including members of the Monterey Bay Area Climate Justice Collaborative (MBCJC), to help define their roles and relationships with respect to the RCPWG’s project development and decision-making processes. By adhering to a bottom-up approach in defining these roles, the RCPWG will develop more inclusive and competitive grant proposals, which in turn leads to more resources for equitable climate work in the region.
| 3

43.10 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
The RCPWG held three workshops between February and May 2024 with members of the MBCJC and other community-based organizations, elected officials, and city/county staff. During the workshops, participants brainstormed successes and challenges in other collaboratives and working groups for which they have participated. This document summarizes the key themes and specific recommendations identified through the workshops around equitable engagement and decision-making.

Through the feedback from the three workshops, the RCPWG prepared guidance around equitable engagement and decision-making. The intended outcomes of this project, through these three workshops, were to:

1. secure commitments for ongoing funding of the RCPWG’s work, including compensation for EJ group participation,

2. continue to build trust and relationships with EJ groups, and

3. cultivate elected and executive champions.

These three outcomes of the workshops and meetings with the Boards of Supervisors and City Councils will enable the RCPWG’s ability to compete and secure funding to more effectively and equitably implement climate projects. The outputs of this project are focused on the operation and implementation efforts of the RCPWG as a group. However, individual jurisdictions may look to adopt similar practices for their own climate response based on the recommendations of this project.

Recommendations for Embedding CBOs into
the Operations and Decision-making
Processes of RCPWG
This document is intended to capture practices and policies for the RCPWG to consider adopting to enable CBO participation in the discussions that are focused on identifying and securing equitable climate funding to implement climate action and adaptation plans in the Monterey Bay Area region. These recommended practices are based on the input shared by CBOs and EJ groups during the workshops.

Recommendations are focused on the following:

1. Operations of the RCPWG: This includes recommendations related to RCPWG , activities, convenings, and decision-making.

2. Decision-making structure of the RCPWG: This includes recommendations related to embedding CBOs into the decision-making governance structure. | 4

43.11 RCPWG
Monterey Bay Area
Regional Climate Project Working Group

3. Recommendations for equity engagement post-awarded grants: This includes recommendations for equity engagement as part of the implementation of funded grant activities.

While one major output of the limited three month USDN grant timeline is to share outcomes of the project with the five jurisdictional elected bodies, the recommendations only pertain to the RCPWG decision-making practices, and not to individual city or county practices.

Recommendations for RCPWG Operations
The recommendations for RCPWG operations can be grouped into three key thematic areas:

1. Continue to strengthen relationships and partner with CBOs;

2. Foster Accessible and Inclusive Communications; and

3. Support Accessible and Inclusive Meetings
Continue to Strengthen Relationships and Partner with CBOs In the RCPWG, it is important to enable conditions for CBOs and EJ groups to be active collaborators. This involves enlisting them as trusted voices representing community needs and compensating them for their time and local expertise. CBOs and public agency/local jurisdiction staff should collaboratively develop a co-designed approach to outreach and community engagement. Having CBOs involved in co-designing community engagement strategies encourages relational-centered and bottom-up approaches that are more likely to result in initiatives and programs that are responsive to the unique needs and priorities of each community.

Below are specific recommended actions/action items CBOs from workshop participants for the RCWPG to consider adopting, related to RCPWG operations:

1. Encourage participation from a diversity participation: Workshop participants encouraged a diverse range of voices to inform RCPWG discussions so organizations representing diverse community groups see themselves represented.
○ Workshop participants identified the following community types:
youth voices and students, the science community, women, indigenous communities, LGBTQ+, people with disabilities, ethnic and racial minorities, faith-based minorities, immigrant populations, low-income or economically disadvantaged communities, rural communities, non-native English speakers, and older adults.
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43.12 RCPWG
Monterey Bay Area
Regional Climate Project Working Group

2. Compensate CBOs and participating individuals from community groups:

Enable participation of CBOs and community members by compensating them for their time with stipends and/or food.
○ Participants identified compensation seen as a form of recognition for expertise, promoting equity, and encouraging involvement. ○ Suggestions for future meetings include further exploring factors behind low uptake, and offering opt-in/opt-out options. ○ Participants also suggested that RCPWG may want to consider using a sliding scale approach. Compensation for participating in a 90-minute meeting can vary for participants based on cost of living, levels of expertise required, and resources available (for example, if a participant is already being compensated through their organization or agency, they may not require an additional stipend).
○ The suggested compensation amounts ranged from $75 to $200 per participant, with the most common recommendation being $100 for a 90 minute meeting.
○ When determining the compensation amount, participants noted that the RCPWG should also consider the additional time requested to be spent on pre-meeting and follow-up assignments. This may warrant stipends rather than hourly rates to account for the preparation and post-meeting activities (e.g., reviewing materials).

3. Partner with CBOs to implement RCPWG activities. CBO participants have indicated their interest primarily in working with RCPWG members in the following RCPWG activities:
○ Participate in RCPWG calls to advise on RCPWG grant strategy (what grants to pursue).
○ Co-develop SOW and/or roles of CBOs in grant applications. ○ Partner to be community outreach liaisons by supporting RCPWG members as equity and outreach consultants as part of planning efforts, and conduct outreach, disseminate information, and advise on, or refine, messaging of communications. See recommendations on post award activities.

Foster Accessible and Inclusive Communications
Effective communication strategies help to facilitate understanding, collaboration, and engagement among stakeholders, fostering a culture of transparency and trust.

Clear messaging is critical for ensuring information is conveyed accurately and comprehensively, enabling informed decision-making and meaningful participation from all stakeholders involved. These practices aim to enhance community engagement and ensure that the initiatives are accessible and understandable to all. | 6

43.13 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Below are concrete recommendations from invited participants on practices and policies for the RCWPG to consider adopting, related to RCPWG operations.

1. Establish shared community agreements: Review shared community agreements at the start of each convening and allow space to adjust. ○ Participants developed community agreements through this process.

See Appendix for the community agreements established during the workshops.
○ One example of a community agreement added by participants is to avoid using highly technical language or jargon. This means providing clear, non-technical communication in presentations and meeting materials to ensure everyone understands. Participants also recommended avoiding using acronyms.

2. Recognize different cultural work ethics: Avoid imposing a specific cultural work ethic that over-prioritizes efficiency and productivity, acknowledging that grassroot solutions require thoughtful deliberation and investment in relationship building, which requires time that does not always conform to grant deadlines.

3. Offer different modes for feedback: Different modes of feedback can encourage participation from a wider range of participants. These include verbal approaches such as open sharing and raised hands, as well as nonverbal options like Jamboard, polling, and email.
○ Participants emphasized the importance of providing multiple opportunities for feedback, such as initial and final reads, and others highlighted the efficiency of polling for quick consensus that also maintains anonymity.

Support Accessible and Inclusive Meetings
The consideration of leading practices for inclusive participation for meetings can promote diversity of perspectives, create a welcoming atmosphere, and ensure equitable opportunities for meaningful engagement, ultimately enriching the outcomes and effectiveness of the meeting. Additionally, it is important for meeting organizers to thoughtfully structure meetings to maximize participants' time and contributions. For example, optimizing meeting logistics can streamline processes, minimize disruptions, and enhance overall engagement.

The following recommendations highlight various leading practices for conducting inclusive, collaborative, and effective meetings. These are recommendations from invited participants for the RCPWG to consider adopting. | 7

43.14 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Meeting structure

1. Concise and focused meetings: Keep meetings concise and focused to respect participants’ time.
○ Workshop participants indicated a preference for concise and focused meetings lasting between 60 to 90 minutes, while ensuring sufficient time for participant feedback and discussion. The duration may vary based on factors such as the frequency of meetings and the importance of the topics being discussed; however, the goal is to strike a balance between efficiency and adequate time for reflection and discussion.

2. Include relevant breaks: Incorporate breaks into longer meetings to accommodate the needs of participants and to maintain engagement. ○ Participants suggested that breaks should typically be in meetings lasting between 90 minutes and 2 hours, or longer, with some advocating for breaks at the halfway point for meetings exceeding an hour in duration. Factors such as whether the meeting is conducted in person or virtually may influence the decision to include breaks.

3. Facilitate breakout sessions: Especially for longer meetings, participants recommended including more breakout sessions for deeper discussions and engagement in smaller groups.
○ Participants discussed the value in having CBOs meet separately in a breakout session before reporting back to the broader RCPWG. This approach can be conducive to more focused engagement and learning across county lines for CBOs involved in climate initiatives. Participants also emphasized the importance of ensuring clarity regarding the purpose and the boundaries of influence participants have in meetings.

Meeting logistics

4. Distribute meeting materials ahead of time: If possible, provide materials to participants to have sufficient time to review in advance of the meetings. With regards to lead time for receiving materials, workshop participants identified the following guidance.
○ Provide 1-2 weeks of time to review materials, depending on the length of review time required, and the complexity of materials (for example, a grant proposal may require more review than a summary report).

Shorter documents (5 pages or less) may require at least one week of review; longer documents will require more review time. ○ Reminders, especially the day before, are helpful for preparation. ○ Participants may wish to coordinate with their team members or board members for feedback, which may require more review time.

5. Accommodate schedules: Identify the best day and time that is appropriate | 8

43.15 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
for all participants. For future scheduling, workshop participants were asked to provide insight on their availability.
○ If possible, future RCPWG meetings will be scheduled to avoid scheduling conflicts with existing board meetings, department meetings, and other regular events within participant organizations. ■ Participants also recommended using web-based scheduling tools, such as Doodle polls or When2Meet.

6. Use engaging tools in presentations: Utilize engaging and interactive tools, such as Mentimeter and Jamboard, to make presentations more engaging and personal.

Inclusive participation

7. Conduct accessibility checks: At the start of each meeting, conduct an accessibility check to identify and address potential barriers to successful participation.

8. Encourage participants to share pronouns: This creates a more comfortable and safe space for all participants to share their preferred pronouns.

9. Relational-centered co-design process: Emphasize a co-design process that values relationships and collaboration, and fosters open discussion.

10. Regularly conduct feedback: Regularly solicit feedback to identify and address barriers to participation.

11. Conduct pre-grant outreach and education: Conduct ongoing outreach, educational sessions, sharing, experiential learning sessions, and planning sessions before grants are announced.

Farallon Strategies’ Additional Recommendations
As the consultant team facilitating this process on behalf of the RCPWG, Farallon Strategies has identified additional recommendations based on the team’s experience integrating CBOs into collaborative governance decision-making processes.

These considerations are for the RCPWG to consider for RCPWG operations, in addition to the recommendations above.
● Clearly articulate how input from CBOs will be used, and the extent of their role in decision-making, at every step in the process.
● On at least an annual basis through discussion, collect feedback and monitor progress on how well recommendations are being implemented. ● Identify or create opportunities for local government staff to learn about CBO initiatives/priorities.
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43.16 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
● Support capacity building of CBOs by connecting them to resources and technical assistance to grow/enhance their ability to deliver programming, and participate in advisory capacity for initiatives, like the RCPWG.

Recommendations for Equity Engagement Design During
Grant Proposal Process and Post-awarded Grants
Several of the practices and policies recommended by workshop participants to implement (or avoid) pertain to the development of the grant opportunities, or to the implementation of the funded grant activities. These practices and policies apply more to broader community and public engagement and outreach as part of the implementation of RCPWG, and other affiliated grant funding. These include leading practices for co-developing and implementing climate response strategies in the Monterey Bay Area Region. It is important to capture these suggestions from workshop participants to consider for the administration of grants in their communities.
● In support of public engagement initiatives related to grants once secured, CBOs can:
○ Facilitate and/or provide space for workshops/town halls for community members;
○ Address language and cultural barriers in communications to community members;
○ Structure conversations and solicit feedback from their own organizations and community members;
○ Build relationships and capacity within the community; and ○ Facilitate fun and cultural activities.
● On a grant by grant basis, ensure that implementation procurement protocols for each specific grant do not preclude participation in scoping the proposal. If a grant does preclude participation, organizations may be asked to recuse themselves from the scoping process.
● Produce documents that meet state accessibility requirements (e.g., for braille readers, etc.).
● For in-person meetings, provide childcare for parents or guardians to enable participation for those who need it.
● Facilitate listening sessions and sharing circles to make sure everyone has the opportunity to speak and give input, and allow for co-creation time. ● Emphasize co-design process for climate strategies / measures. ● Pair climate solutions with the most needed community resources, i.e. affordable housing.
● Lift marginalized voices, including women, by putting them first on the agenda and providing eliciting prompts.
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43.17 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
● Offer translation services to reduce language barriers and encourage participation from diverse linguistic backgrounds (e.g., English, Spanish, and Indigenous languages, etc.).
● Reduce language barriers by providing literacy-reviewed material for community members.
● Distribute materials in various formats for communication (e.g., send more than mailers).
● Avoid meetings during working hours.
● Meet people where they are for community and in-person events: Make information accessible to the public by canvassing or going out to meet the public in community locations, such as farmers markets and parks. Work with CBOs to identify events and locations that draw crowds to set up tabling materials for in-person events.
● Continue projects even when grant funding ends.
● Provide technical assistance pre- and post- presentations or concepts where technical elements are included. Identify focus areas for feedback in areas that residents/CBOs can respond.
● Adopt a bottom-up approach to needs assessments, involving all stakeholders in the planning process when grants are identified.
● For engagement specified in grant programs, RCPWG members can invest in their relationships with CBO partners and community members by hosting in-person meetings when possible, or attending CBO meetings/events. | 11

43.18 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Appendix
Appendix A: RCPWG Acronyms
● CAP: Climate Action Plan
● CBO: Community-Based Organization
● CERF: Community Economic Resilience Fund
● CJC: Climate Justice Collaborative
● EJ: Environmental Justice
● MBACJC: Monterey Bay Area Climate Justice Collaborative ● RCPWG: Monterey Bay Area Regional Climate Project Working Group ● RFP: Request for Proposal
● TCC: Transformative Climate Communities
● USDN: Urban Sustainability Directors Network
Appendix B: RCPWG Interim Charter
The interim RCPWG charter was developed through discussions with the Monterey Bay Area Regional Climate Project Working Group (RCPWG) in 2023.

The Challenge and Opportunity
Climate change is a priority issue for organizations across the Monterey Bay Area Region. A focused and organized approach to accessing historic State and federal funding and resources is required to bring the region together to collectively achieve equitable and resilient outcomes. Access to large scale transformative grant opportunities has the potential to accelerate implementation of climate change mitigation and adaptation projects and programs across the three-county region.

The Monterey Bay Area Regional Climate Project Working Group (RCPWG) was formed to regionally work together to access more funding to address climate change.

RCPWG Mission
The mission of the Regional Climate Project Working Group (RCPWG) is to collaborate among groups and organizations in the Monterey Bay Area region, including Santa Cruz, San Benito, and Monterey Counties, to develop, prioritize, secure funding for, and effectively and equitably advocate for and implement regionally beneficial climate mitigation and adaptation projects and programs. | 12

43.19 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Membership
RCPWG membership are dues-paying city/county governments. Regional agencies, nonprofit 501(c)3 organizations, or tribal organizations/ governments members may serve as advisors and attend RCPWG meetings upon consent of the RCPWG.

RCPWG members make decisions with respect to what grants the RCPWG pursues, appropriate advisors, subcommittee formation, as well as decisions related to the future membership/leadership of the RCPWG as it evolves.

The RCPWG may decide to change the composition of the RCPWG to a different structure or to add representation from other organization types once established.

Leadership
The RCPWG is led by a Chair and Vice Chair. The term of the Chair and Vice Chair will be one year. Until officer elections took place, the RCPWG Managing Consultant (Farallon Strategies) led the scheduling of meetings, will set agendas, and facilitate RCPWG meetings. The scheduling of meetings, agenda development, and facilitation of RCPWG meetings are closely coordinated between Farallon Strategies and the Chair and Vice-Chair. The Chair and Vice Chair approve work plans and invoices for the consultants, are the final decision maker on any agendas, and have the signatory authority on behalf of the RCPWG.

Decision-Making
The RCPWG will make decisions with respect to what grants the RCPWG pursues, subcommittee formation, as well as the future membership, leadership, and dues structure of the RCPWG as it evolves. Decisions will be made by consent, meaning the absence of objections, which supports accelerated decision-making.

Dues and Stipends
The RCPWG provides members with access to an established network of regional partners, grant identification and writing assistance, and grant dollars awarded for each grant secured. Each RCPWG member pays dues to be able to participate in voting. Dues will be periodically updated and maintained in an online location and format where all members will have access to the document. The Community Foundation for Santa Cruz County (CFSCC) is the fiscal sponsor for RCPWG.

Sub-Committees
Sub-committees of the RCPWG will be established to support the mission of the RCPWG with respect to specific focus areas (e.g. building electrification, transportation, etc.). Sub-committees will have the primary focus of identifying, developing, and if awarded, implementing grants. Each subcommittee must have a | 13

43.20 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
minimum of three participating RCPWG members, and one member who is willing to serve as a working group liaison.

The Sub-committee Liaison is responsible for creating agendas, facilitating sub-committee meetings, advancing the subcommittee toward its agreed upon purpose, reporting back to the RCPWG (verbally or in writing) on the progress and decisions of the subcommittee. The RCPWG has the ability to initiate or sunset a sub-committee through standard voting procedures.

Meetings
Members of the RCPWG are expected to attend and participate in regular RCPWG meetings. The RCPWG meet virtually every six weeks for up to two hours.

Sub-committee meeting frequency will be determined by Sub-committee Liaisons based on input from subcommittee members. Meetings will be run using a consent model with quorum being 3/5ths of members being present.

Appendix C: RCPWG Activities
Members of the RCPWG benefit from learning about grant opportunities, jointly developing competitive grant proposals, and accessing an established network of partners that can lead the development of grants and implementation of projects that address climate change in the region.

The RCPWG Strategy Team meetings are conducted to discuss RCPWG administration and upcoming grant opportunities. Additionally, RCPWG leadership (currently a Chair and Vice-Chair) meet with the Consulting Team, as needed, to discuss consultant contract obligations, plan for upcoming meetings, and the status of securing new and existing grant opportunities.

The primary activities of RCPWG members include:
● Share knowledge of grant opportunities and project updates across jurisdictions,
● Design roles in grant proposals,
● Scope projects for grant proposals,
● Participate in grant funded roles and projects,
● Evaluate grant proposal preparation and project execution process, ● Attend one call every six weeks, or as-needed, to discuss RCPWG operations and grant opportunities,
● Hire and manage consultants,
● Collectively decide which grants to pursue and how to pursue them, and | 14

43.21 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
● Support ongoing discussions of governance for RCPWG and equity considerations.

As described in the charter, the RCPWG members use consent-based decision making with respect to:
● What grants the RCPWG pursues,
● Which advisors to invite to participate in discussions (including regional agencies, nonprofit 501(c)3 organizations, or tribal organizations/governments), ● Subcommittee formation,
● Membership and Leadership, and
● Dues structure.

Appendix D: Workshop Materials
Workshop Participants
Invited Participants Organization Workshop #1 Workshop #2 Workshop #3 Tatiana Brennan
Santa Cruz County X X X
Elissa Benson
Santa Cruz County
Dave Reid Santa Cruz County
David Carlson County of Santa Cruz X X X
Sierra Ryan County of Santa Cruz X X
Justin Cummings
Board of Supervisors Chair (Santa
Cruz County)
X X
Cora Panturad Monterey County X X X
Supervisor Luis Alejo Monterey County X X
Javier Gomez
Policy Analyst for Supervisor Luis
Alejo (Monterey County)
X
Courtney Lindberg City of Watsonville X X
Jackie McCloud City of Watsonville X X X
Tiffany Wise-West City of Santa Cruz X X X
Mayor Fred Keeley Mayor of Santa Cruz
Member Martine
Watkins
City of Santa Cruz X
Celina Stotler San Benito County X X
Arielle Godspeed San Benito County X X X
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43.22 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Invited Participants Organization Workshop #1 Workshop #2 Workshop #3 Steve Loupe San Benito County X
Abraham Prado
San Benito County
Supervisor Kollin
Kosmicki
San Benito County X X
Observers
Donovan Arteaga City of Salinas X X X
Erika Senyk City of Capitola X X X
Carmen Gil City of Gonzales
Jessica Olmedo-Albor City of Gonzales X X
Amaury Bertead AMBAG, RCPWG Advisory Member X X X
Kirsten Liske
Ecology Action, Grant
administrator and RCPWG
Advisory Member
X X X
Community-Based Organizations
Eloy Ortiz Regeneración X X X
Maria Elena Manzo Mujeres en Acción X X X
Leslie Austin
Let's Green CA / Romero Institute X X X
Elaine Johnson
NAACP Santa Cruz Chapter (and
Dir, Housing Matters)
X X X
Rene Casas Youth for All X X X
Alex Lopez
Center for Community Advocacy X X
Tyler Scheid
Black Leaders and Allies
Collaborative
X X X
Karina Moreno MILPA X X
Maria Cadenas Ventures X X X
Brando Sencion Ventures X X
Agustin Angel Leaders4EARTH X
Workshop 1
The practices below are transcribed from the Jamboards used in Workshop 1. To help the RCPWG members prioritize near term adoption of practices for equitable CBO engagement in the RCPWG, workshop participants added a “+1” to practices they wanted to emphasize. The number of +1s that people added are denoted in parenthesis next to the best practice or policy.
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43.23 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
What practices and policies have you seen worked?
● Bilingual Engagement (+3)
● Childcare at meetings (+1)
● Incorporating youth voice (+1)
● Ongoing research, education, sharing, experiential learning sessions, and planning sessions before grants are administered (+1)
● Regularly solicit feedback to help identify any issues or barriers to participation (+1)
● Pair climate solutions with the most needed community resources, i.e. affordable housing (+1)
● Including groups who are doing similar work in the community and compensating them for their time (+1)
● Meeting people where they already are: farmers markets, parks, etc rather than holding meetings in a facility/time that is inconvenient (+1) ● Engage CBOs to serve as liaisons to the community - structure the conversation, identify the appropriate topics for feedback, in-language and culture connections
● provide food/ break bread together
● documents produced should meet state accessibility requirements (eg for braille readers, etc.)
● Language Access, including indigenous languages
● Clearly articulating how the policy/practice is being applied to decision-making activities
● encouraging sharing pronouns if comfortable
● day of week/time of day...ensuring it works for all
● Engagement with the science community
● Hiring local CBOs as equity and outreach consultants as part of planning efforts
● Find ways to engage in personal relationships. Doesn't always have to be 'official'.
● Using Sharing circle processes to make sure everyone has the opportunity to speak and give input
● Distribute meeting materials ahead of time if possible ● Using CBO's as a liaison for outreach, disseminating information, building relationships and capacity
● Clear, non-technical communication to ensure everyone understands ● Translations services to ensure language barriers do not hinder participation ● Leading from a Relational-Centered approach and NOT a Transactional approach.
● Hiring CBO's to host workshops/town halls for community members with food and/or stipends
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43.24 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
● Emphasize Co-design process for climate strategies / measures ● Listening sessions with community members
● Compromise
● Engaging with students
● Literacy reviewed material for community members
● Providing technical assistance pre and post presentations or concepts where technical elements are included. Focusing feedback in areas residents/CBOs can respond
● Accessibility of information to the public. Canvassing or going out to meet the public.
● Using mentimeter (or the like) to make presentations engaging and personal. ● Working with community partners to identify events/locations that draw crowds to set up tabling materials
● Keep meetings concise and focused to respect participant's time ● Developing relationships with community members so the relationships do not feel transactional
● Including groups who are doing similar work in the community and compensating them for their time
● conduct an accessibility check at the start of each meeting ● offer different modes for feedback
● Have events with fun activities and food
● Our Safe Routes to Schools parent meetings were successful being held online in early Evening in Spanish -families have that capability due to schools during
● Compensation of liaison CBOs and meeting participants ● Marginalized voices agendized first and foremost with eliciting prompts, including women first.
● produce shared community agreements at start of each convening and allow space to adjust those
● The MBACJC has a 40 minute section in each meeting for climate project presentations, discussions or co-creation with language access provided. | 18

43.25 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
What practices and policies should we avoid? Please include suggestions for improvement.
● English only presentations. Highly technical presentations (+1) ● Deciding for the community on what they need (+1)
● Presentations that emphasize education and listening only (+1) ● Don’t start this work and then drop it if grant funding ends (+1) ● Postcard mailers as the only form of communication
● overly complicated policies and long processes that make it feel hard to take action
● Hosting meetings from 8-5. Consider after hour meetings so community members can attend.
● Assuming that the link between climate change or mitigation strategies/benefits are apparent to all stakeholders
● Avoid imposing a specific cultural work ethic (hard to do when you have a timeline)
● Avoid meetings during working hours
● Limiting community feedback to a specific scope (transportation electrification ) when they may want to share about broader priority concerns, ● Avoid ignoring local potential (nurture local partnerships and address challenges that hinder their development)
● Avoid overly technical language and jargon
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43.26 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Workshop 2
Community Agreements
| 20

43.27 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
San Benito County
| 21

43.28 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Santa Cruz County
| 22

43.29 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
| 23

43.30 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
| 24

43.31 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Monterey County
| 25

43.32 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
| 26

43.33 RCPWG
Monterey Bay Area
Regional Climate Project Working Group
Workshop 3
Breakout Room for CBOs participating in USDN Workshops
| 27

43.34 Advancing Equitable,
Shared Climate
Investment
Decision-making
An Update on the Monterey Bay Area
Regional Climate Project Working Group
Tiffany Wise-West
Sustainability + Resiliency Officer

43.35 Collaborate among groups and organizations in
the Monterey Bay Area region, including Santa
Cruz, San Benito, and Monterey Counties, to
develop, prioritize, secure funding for, and
effectively and equitably advocate for and
implement regionally beneficial climate
mitigation and adaptation projects and
programs.
2 RCPWG Mission

43.36 3
Three virtual workshops between February and May 2024
Goals:
● Secure commitments for ongoing funding of the RCPWG’s work, including compensation for environmental justice groups and community based organization participation,
● Continue to build trust and relationships with CBO and EJ groups, and ● Cultivate elected and executive champions.

Advancing Equitable Decision-making on Climate Investments 1 2
3 43.37
An Intersection of Regional Efforts
4 Regional Climate Project
Work Group (RCPWG)
+other observing
jurisdictions
Monterey Bay Area
Climate Justice
Collaborative (MBACJC)
+ Other CBOs
Monterey Bay Area Regional Climate
Investment Decision-making Workshops
(through financial support of Urban Sustainability Directors Network)

43.38 Project Outcomes
5 Guidance developed around equitable
engagement and decision-making
8 RCPWG commitments to CBO and
EJ groups moving forward

43.39 Recommended Motion to:
6 8 RCPWG commitments to CBO and
EJ groups moving forward
1) Accept the presentation on the activities of the Monterey Bay Area Regional Climate Project Working Group (RCPWG); and
1) Adopt a resolution affirming the City Council’s intention to commit to funding the City of Santa Cruz’s contribution for the RCPWG for three (3) additional years (through FY 2027), if feasible given the status of the General Fund.

43.40 Thank You
Questions?

43.41 44.1

44.2 44.3

44.4 44.5

44.6 44.7

44.8 44.9

44.10 44.11

44.12

Santa Cruz City CouncilJune 25, 2024

Santa Cruz City Council
June 25, 2024