Significance

What’s already known Prevalence of sugar-sweetened beverage (SSB) intake is declining among some subpopulations in the United States. SSBs are still widely consumed and contribute to racial, ethnic, and socioeconomic disparities in childhood obesity and related chronic disease.

What’s new Community engagement and clear messaging about the health and financial benefits that marginalized communities will receive from SSB policies may help increase support for policies and programs to reduce SSB consumption starting early in life.

Introduction

In New York City (NYC), geographic disparities in health are apparent early in life (Schonfeld & Sweeney, 2018). Racial/ethnic and socioeconomic segregation exists, and residential zip code is tied to health outcomes (NYC Health, 2019). These disparities are the result of decades of structural racism, discriminatory redlining and zoning, and inequitable policies, and are even more pronounced in the wake of COVID-19 (Adhikari et al., 2020; Gee, 2008).

Racial/ethnic and socioeconomic health disparities are particularly concerning when it comes to obesity and related chronic diseases, as chronic disease is the leading cause of death for New Yorkers, and obesity is linked to severity of COVID-19 (Yi et al., 2014). These disparities originate early in life and portend disparities in acute public health crises, as evidenced by the disproportionate number of Black and Hispanic/Latino people who die from COVID-19 (Webb Hooper et al., 2020). By early childhood, racial/ethnic disparities in obesity have already emerged, which suggests the need for earlier intervention and restructuring of the systems that undergird these disparities (Blake-Lamb et al., 2016). Washington Heights has a population of almost 200,000, of which 23% consume SSBs every day. Similarly, close to 400,000 people live in the South Bronx communities, and about 30% of them consume SSBs daily (Community Health Profiles). In Washington Heights, almost half of children aged 5–14 years have overweight or obesity (A Foodscape of Washington Heights/Inwood, 2017), and in the South Bronx, about 40% of children aged 5–14 years have overweight or obesity (A Foodscape of The South Bronx, 2017). Modifiable risk factors in the first 1000 days—gestation to age 2 years—mediate racial/ethnic disparities in childhood obesity, making this a critical period to intervene for childhood obesity prevention in NYC neighborhoods like Washington Heights and the South Bronx (Woo Baidal et al., 2016).

The disproportionate burden of obesity among marginalized populations highlights the urgent need for policies to achieve health equity. Excessive intake of added sugars, especially in the form of Sugar-sweetened beverages (SSBs), is a risk factor for obesity (Muth et al., 2019). Specifically, increased SSB consumption during pregnancy is associated with greater adiposity in mid-childhood (Gillman et al., 2017), and SSB consumption in infancy significantly increases the likelihood of obesity at age 6 years (Pan et al., 2014). These findings suggest that pregnancy and infancy are critical periods for establishing healthy beverage consumption. SSB intake is highest in Hispanic/Latino and non-Hispanic Black children in NYC (Adjoian & Lent, 2017). Despite continued efforts to decrease SSB consumption in Black and Hispanic/Latino communities, childhood obesity disparities persist in NYC.

There is a dearth of data in the qualitative literature focusing on community perceptions of SSB programs and policies in Black and/or Latino populations in NYC. However, mounting evidence shows community participation plays a key role in advocacy and implementation of health promoting policies. In San Francisco, a study found that community engagement is essential to mobilize advocacy and successfully restrict SSB purchases (Grumbach, 2017). In this study, we sought to understand community perceptions of policies and programs targeting reduction of SSB consumption in the first 1000 days in two neighborhoods where there is a high prevalence of childhood obesity and the majority of residents identify as Black and/or Latino (A Foodscape of Washington Heights/Inwood, 2017; A Foodscape of The South Bronx, 2017).

Methods

Study Design and Approach

We performed a qualitative research study to elicit perceptions of interventions aimed at reducing SSB consumption in pregnancy and infancy, including perceived facilitators and barriers of implementing such interventions in Washington Heights and the South Bronx. We recruited stakeholders from different sectors of the community.

Conceptual Framework

The conceptual framework of this study is based on a modified version of the Glass and McAtee model of the multilevel influences of behavior (Glass & McAtee, 2006). The current study focused on SSB interventions at the macro (e.g., SSB taxation and policies), meso (e.g., targeted health messaging campaigns), and micro (e.g., community level programs) levels. We organized our codebook, analysis, and results according to different levels of influence.

Study Setting and Participants

We conducted semi-structured, in-depth interviews with community members and leaders from Washington Heights and the South Bronx. We used purposive and snowball sampling to recruit participants from Community-based organizations (CBOs), faith-based organizations, childcare centers, and local government. These organizations were selected because they have influential power on community members and SSB community programming most relevant to this study. Participants were considered eligible if they were older than 18 years and lived in Washington Heights or the South Bronx. Community members with no experience with pregnancy or infancy and those who could not answer questions in English or Spanish were excluded. All leadership levels were invited to participate if they met eligibility criteria. Interviews took place in-person at Columbia Community Partnership for Health or at participants’ place of work. Interviews occurred between July and November 2019.

Instrument Development

We performed a literature review to identify existing and effective interventions, policies, and public health campaigns aimed at reducing SSB consumption. After multiple meetings with co-authors, including community members or community organizers, we developed a semi-structured interview guide (Table 1) and provided visual aids including images of various SSBs, infographics of SSB policies and programs, and a short video about the harmful effects of SSB consumption. All materials were available in English and Spanish.

Table 1 Interview guide domains and sample interview guide questions
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Data Collection

After participants provided informed consent, they completed a demographic questionnaire and a 60-min, in-person, individual, semi-structured interview in English or Spanish. All interviews were conducted by trained interviewers concordant with participants' language preference. All interviews were audio-recorded and transcribed verbatim in English or Spanish with an English translation for analysis. Detailed notes were taken by research staff to account for non-verbal cues. Compensation was given to all participants in the form of a $50 gift card. Interviewing occurred until data saturation was reached, as ascertained by the team during their iterative analysis of the transcripts. The New York City Department of Health and Mental Hygiene (NYC DOHMH) provided conceptual support in study design and identifying relevant public health programs and policies, and the Institutional Review Boards of Columbia University Medical Center and NYC DOHMH approved all study protocols.

Analytic Approach

We performed data collection and analysis in iterative cycles. First, we conducted content analysis using immersion/crystallization techniques (Borkan, 1999), which involved research staff listening to the audio-recorded interviews and reading the transcriptions. The analytic team met recurrently to review transcripts and notes from previous interviews and discuss emerging themes. Next, we utilized notes from weekly meetings to develop a codebook for template style analysis (Crabtree & Miller, 1999). The codebook was modified as necessary to accommodate the need for additional codes. Interviews were coded using NVivo Version 12 by two investigators (LB, KN) for the first five interviews, and one main coder (LB) thereafter. In recurring meetings, the analytic team ensured coding was appropriate and used the software’s code query reports for further immersion/crystallization analysis and resolved any discrepancies in understanding of the data until reaching final interpretation of the findings.

Results

Participant Characteristics

We interviewed nine community members and 10 community leaders. Eight participants were from Washington Heights, and 11 were from the South Bronx. Leaders included local government officials, community board members, and employees from CBOs and faith-based organizations. Of the 19 interviews, 12 were conducted in English and seven were conducted in Spanish. Most community members identified as Hispanic/Latina/Spanish, and some identified as Black/African American. Most community leaders who participated in this study identified as white/Caucasian, and some identified as Hispanic/Latino. All participants identified as female. Ages ranged from 28 to 60, mean [SD] age was 40 [7] years.

Perceived Facilitators and Barriers to Policy and Program Implementation ( Table 2 )

Table 2 Perceptions of facilitators and barriers to implementation of SSB policies and programming during the first 1000 days
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Long-Term Engagement with Broad Coalitions of Stakeholders is Necessary for Successful Public Health Programming and Policy

Almost all participants emphasized the importance of building committed coalitions with a diverse range of stakeholders when implementing public health programming and policy. Examples of these stakeholders included small businesses, schools, bodegas, and parks departments. Several participants stressed the importance of long-term partnerships. Many participants cited community buy-in as crucial to generate support for SSB policy, and several brought up the idea of “meeting people where they are at” as a way to build community trust. Examples of this included offering alternatives to unhealthy beverages, making an effort to work around families’ schedules, and supporting community-driven change rather than “demanding” it.

Continual Education is Key but Not Enough on Its Own to Reduce SSB consumption

Many participants believed that consistent, repetitive messaging at the macro, meso, and micro levels needs to be partnered with policy and programming to generate meaningful change in SSB consumption. Several participants stated that visual aids and images that portrayed beverage sugar content and harmful effects of SSBs most effectively convey risks associated with SSB consumption and promote healthy beverage consumption.

In Washington Heights and the South Bronx, Programs That Address the Lack of Accessibility of Healthy, Affordable Foods are Often Also Difficult to Access

Many participants noted that healthy foods and beverages are not easily accessible or affordable in Washington Heights and the South Bronx. While some participants emphasized the importance of access to healthy food, others emphasized the need for conveniently timed and located nutrition/health programs. Participants universally believed that time and distance constraints play a major role in determining the accessibility of nutrition programs and resources. Conversely, several participants mentioned the abundance of unhealthy foods and fast food restaurants in these neighborhoods and suggested this might prevent people from eating healthfully. Both community members and leaders stated that parents in these communities generally want their children to eat healthfully, but lack of access to healthy food and health education programming is a major barrier.

Perceptions of Potential SSB Interventions ( Table 3 )

Table 3 Perceptions of potential interventions to reduce SSB consumption during the first 1000 days
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Macro Level: General Policies

SSB Taxes Remain Divisive, But There is Broad Support for Using Tax Revenue to Fund Community Improvement

While most participants were in favor of an SSB tax, some strongly opposed it and believed it would not be an effective strategy to decrease SSB consumption. Participants in support perceived that an excise tax would help to curb SSB consumption by reducing access to unhealthy beverages and increasing community awareness of SSB-related health consequences. Conversely, community members who opposed the tax believed that SSB consumption is an addiction, and therefore those who consume SSBs would not be willing or able to reduce consumption regardless of cost. Others expressed distrust in the government and were concerned that revenue from SSB taxes would go to the state rather than to communities. Community leaders who opposed the tax feared the tax would “punish” families of low socioeconomic status.

When asked how revenue from an excise tax should be used, all participants expressed a desire for community improvement. Many stated that tax funds should be returned to the community from which they were collected. One participant stressed the importance of avoiding a “tax for nothing.” Most participants felt tax revenue should be used to fund health/nutrition education programs, improve community parks, launch awareness campaigns, and improve schools.

Non-SSBs as Default Kids’ Meal Option in Restaurants Will Decrease Child SSB Consumption

Community members and leaders supported policies that require restaurants to provide drinks without added sugars as the default beverage in children’s meals. Under Int. 1064–2018, a NYC-specific law that amends the administrative code of the city in relation to selections for beverages included in children's meals, parents can still request a different beverage at no additional charge, but the default beverage is water, low-fat milk, or 100% fruit juice (Int. 1064–2018). Almost all participants agreed that making healthy beverages the default option would be an effective strategy to decrease children’s SSB consumption. Overall, the element of choice was viewed as positive; however, some felt this law could go further in terms of restrictions. One participant noted “parents can still substitute for the beverage. That’s the problem, the asterisk.” Several community members suggested there may be initial resistance from parents regarding the law–both because of a lack of education and a feeling that the government is “dictating to them how to live.” Although this law (Int. 1064–2018) passed in NYC in April 2019 prior to this study, few community members were aware of its existence.

Meso Level: Wellness Policies and Messaging

Reducing Juice and Sugary Drink Availability in Childcare Settings Can Deter SSB Consumption, But Parents May be Initially Resistant

All participants were in favor of Article 47 of the NYC Health code, which prevents federally funded group childcare centers from serving beverages with added sugars, including flavored milks, and limits the amount of 100% fruit juice that can be served to 4 oz. One participant expressed reservations around the restriction of chocolate milk but supported the regulations overall. Several community members referred to the regulations as “perfect,” and community leaders generally believed that the regulations “make a lot of sense,” although some felt the regulations could go further to completely remove juice from childcare environments. Several participants said that restricting SSBs in childcare settings could help to reduce dental disease, hyperactivity, and sugar addiction among children. Many participants thought parents might be more hesitant to accept regulations than children but believed they would eventually support the bill. Some participants mentioned children’s adaptability, with one stating “If you don’t give it to a kid they won’t know what they’re missing.”

Video Messaging Equating the Health Hazards of SSBs to Tobacco is Seen as Impactful by Some and as Confusing by Others

Interviewers showed participants “Which One,” a video released by the NYC DOHMH that compares the health hazards of SSB consumption and tobacco use. While community leaders were more skeptical than community members around this messaging campaign, both groups were generally supportive. Participants used words like “strong,” “impactful,” and “direct” to describe the message, and several participants believed it was a good idea to compare SSBs to cigarettes because they are both addictive and “both kill.” Some believed that community members may not fully understand how harmful SSBs are and that this video could help raise awareness.

While participants were mostly supportive of the video campaign, some held reservations about the comparison of SSBs to cigarettes. One community member and one leader strongly opposed the comparison, describing the video’s message as “confusing” and misleading because tobacco use is more harmful than SSB consumption and also has the capacity to harm others. Others who felt conflicted about the video’s message stated that the comparison of SSBs to cigarettes is like “apples to oranges.” Several participants were concerned that they had never seen this video campaign.

Micro-Level: Community-Based Programs

Though Participants Were in Favor of Community-Based Programming, Most Were Unfamiliar with Existing Programs

Most participants were unfamiliar with Shop Healthy NYC and the Bronx Healthy Beverage zone, two community-based programs that work to promote healthy beverage consumption in NYC communities with high rates of obesity. Of those who were familiar with these programs, almost all were community leaders, and most were only familiar with Shop Healthy NYC, a program led by the NYC DOHMH that encourages local stores to increase promotion of healthy foods and encourages healthier purchasing by placing healthier items, such as water, at eye-level and near cash registers (Shop Healthy – NYC Health, 2013). Participants were conflicted about the effectiveness of this program, and one person noted “it’s really funny because it totally depends who you ask how successful it is.” Several who were unfamiliar with community programs expressed an interest in learning more about them.

Discussion

In this qualitative study of community members and leaders in Washington Heights and the South Bronx, most participants believed a multi-pronged approach is necessary when implementing interventions to reduce SSB consumption during the first 1000 days of life. Strategies that incorporate community engagement, access to programs and healthy beverages, funds reinvestment, and continual clear messaging and educational campaigns may help with implementation of policies and programs. Effective policies to curb SSB consumption during this critical period of development could help reduce childhood obesity and provide a strong foundation for lifelong health.

Limited access to healthy beverages, targeted product placement, and advertising placement practices that reinforce structural racism in Black and Hispanic/Latino communities contribute to health disparities (Dowling et al., 2020). In this study, participants stated that lack of access to healthy beverages and exposure to confusing health messaging were barriers to uptake of policies that support SSB avoidance in the first 1000 days. A systematic review of childhood obesity among Hispanic/Latino children emphasized the importance of cultural influence and suggested that providing culturally appropriate materials can lead to more successful implementation in this community (Branscum & Sharma, 2011). Results from our study support use of culturally inclusive messaging, as well as restricting racially targeted advertising of SSBs. Because participants were strongly in favor of policies and programs that strive to improve the health of pregnant women, infants, and children, this suggests a shift in health messaging to focus on the health of these populations might also be a facilitator to reduce SSB consumption.

Our findings support existing literature showing that community member engagement is crucial for the successful implementation of SSB-curbing policies. Among our interview participants, SSB tax policy was a controversial issue. In a prior qualitative study, messaging on the health effects of SSB consumption and plans to reinvest funds into obesity prevention programs were perceived by policy experts as strategies to generate community support for SSB taxes (Jou et al., 2014). A recent qualitative study in South Africa revealed participants’ perception that funds generated from SSB taxes should be directed back into programs for youth development and mass media education (Kaltenbrun et al., 2020). In our study, despite providing participants with evidence of the effectiveness of SSB taxes in California, some interview participants were skeptical about how tax revenue would be reallocated in New York City, and mistrust of government contributed to a lack of belief that revenue from an SSB tax would benefit Black and Hispanic/Latino communities. In order to offset mistrust around a future SSB tax, NYC politicians should consider combining policy efforts with community-focused awareness campaigns that delineate exactly how and when funds will be used to improve health outcomes in low-income NYC communities.

Amid the COVID-19 crisis, many cities are looking for creative ways to protect the health of communities. In two Mexican states, officials believe that banning junk food sales to minors will reduce rates of obesity and diabetes and, consequently, reduce the deadly effects of COVID-19 (Fredrick, 2020). Furthemore, in Mexico, taxation policies reduced SSB purchasing in low-income communities the most and this effect was maintained even two years after implementation of the SSB tax (Colchero, 2017). In Seattle, the SSB excise tax, which was implemented in 2018 (CHOICES Project, 2018), has yielded a 22% decrease in SSBs sales (Powell & Leider, 2020), and during the COVID-19 epidemic, SSB tax revenue has funded food-assistance programs and provided thousands of low-income families with supermarket vouchers (Beekman, 2020; Yan, 2020). Two studies from California where SSB taxation has been successful found that community advisory boards were essential for adequate revenue allocation to the most underserved communities (Asada, 2021; Falbe, 2020). The incorporation of tax revenue regulations that restrict funds to community reinvestment into future SSB policy and the creation of advisory commissions will be integral to increasing community support for SSB taxes in Washington Heights and the South Bronx. Our findings suggest that widespread engagement combined with messaging about the health consequences of SSB consumption and equitable allocation of SSB tax revenue may help garner support for an SSB tax policy among Black and Hispanic/Latino communities.

In general, community members felt similarly to those in leadership roles about barriers and facilitators to SSB policies in NYC, with the exception of barriers to SSB tax implementation. Community leaders were concerned about the tax unfairly affecting low-income families, while community members were concerned about addiction and inability to change behaviors. Though a 2019 study examining addictive properties of SSBs found preliminary evidence of withdrawal symptoms and increased cravings during cessation (Falbe et al., 2019), a study of the Berkeley Soda Tax found that simply enacting an excise tax was enough to alter consumers’ SSB purchasing behavior (Taylor et al., 2019). Furthermore, a main criticism of excise taxes is that they place an undue burden on low-income populations, so it is notable that community members expressed less concern over equity and more over the effectiveness of the tax compared to community leaders. The CHOICES research group estimated that households spend less on SSBs after an excise tax goes into effect, providing disposable income for other purchases (CHOICES Project, 2018). Similarly, in Philadelphia, a study found significant declines in volume of taxed beverages sold after the implementation of an SSB tax- specifically in small independent stores more frequented by low-income populations (Bleich et al., 2020; Roberto et al., 2019). The combined findings from the CHOICES group and the Philadelphia tax suggest that the greatest long-term health benefits and reductions in health care costs will accrue to low‐income consumers, who consume more SSBs.

Participants generally favored policies aimed at impacting drinking behavior in the first 1000 days and improving the health of children, such as policies targeting children’s meals and beverage regulations at childcare centers. Studies in Baltimore and California found that subtly influencing or “nudging” the choices of families in restaurant settings has high rates of community acceptability, increases understanding of the benefits of healthy beverages, and reduces SSB consumption (Yang & Benjamin-Neelon, 2019). While this tactic may not be as effective as an SSB tax, it makes the healthy choice the easy choice and supports a culture of healthy beverage consumption (Bleich et al., 2020). Participants had high acceptability of the regulation of juice and flavored milk at childcare centers. Participants showed less support for community-based programming that requires active participation because of time and distance barriers.

A limitation of this study is the inherent ambiguities of human languages, especially with Spanish and English translations. To minimize potential bias, all interviewers were trained in culturally sensitive interviewing techniques, and all interviews were language concordant. Because all participants spoke English or Spanish, perspectives may not represent the views of people in NYC who speak other languages. Although our participation criteria did not exclude persons of other genders, all participants identified as women, and therefore our results may not reflect the perspectives of persons of other gender identities. Additionally, this study has a small sample size and low generalizability. However, through purposive sampling of community leaders and members, we ensured inclusion of individuals with the range of demographics and perspectives relevant to this study. Despite these limitations, this study provides key information about two low-income neighborhoods greatly affected by childhood obesity.

Despite a growing body of evidence linking SSB consumption and adverse health outcomes, there is little known about community awareness and perceptions of SSB programs and policies in low-income Black and Hispanic/Latino communities. Though some studies have explored community perceptions of SSB policies and programs, this is the first study to focus on the perceptions of low-income Black and Hispanic/Latino communities. Low-income communities of color are disproportionately affected by obesity and are more likely to consume SSBs, and therefore more research around strategies to more effectively implement SSB interventions in these communities is necessary.

Conclusion

In this qualitative study, community members and leaders who were interviewed in Washington Heights and the South Bronx supported the creation of healthier environments for children and were amenable to many current and potential SSB policies. Community members perceived that the main barriers to healthy beverage consumption included lack of access to healthier beverage alternatives, lack of knowledge about the health effects of SSBs, and challenges with accessing community programming. A few had concerns that SSB consumption was an addiction. Community leaders cited the main barrier to SSB policy implementation as lack of community support for policies. Both community leaders and members in this study favored childcare beverage regulations that made the healthy choice the default choice. Participants perceived that a multifaceted approach to SSB policy is necessary to reduce SSB consumption.

Disparities in COVID-19 mortality rates have underscored the role that race, socioeconomic status, and geography play in acute and chronic disease. Policies aimed at improving health outcomes in low-income, Black, and Hispanic/Latino communities must be firmly rooted in principles of health equity and community support.