The Healthy Beverage Initiative: An Early View of the Metabolic Substudy

Elsa Michelle Esparza, Alison Hartman BA, Dr. Cindy Leung ScD MPH, Samantha Schilf BA, Angela Wackerly BA,
Laura Ishkanian MPH, Leeane Jensen BA MA MPH, Dr. Robert H. Lustig MD, *Dr. Laura Schmidt PhD MSW MPH, *Dr. Elissa Epel PhD
University of California, San Francisco Department of Psychiatry, San Francisco, CA 94118 *co-principle investigators
2016 UCSF Summer Research Training Program

Abstract Measures Methods Results
Sugar sweetened beverages (SSB’s) are the leading single source of added
sugar in the American diet, representing 39% of the added sugar we consume
Anthropometric Measures of Adiposity The Healthy Beverage Initiative The Intervention group was more likely to report
(DGA 2015). Consumption of sugar-sweetened beverages may be a key • BMI reduced SSB intake. No difference between groups
contributor to the obesity epidemic because of the high added sugar content, as to how much they reduced.
low satiety, and incomplete compensation for total energy (Malik et al, 2016). In • Waist Circumference
response to these concerns, The University of California, San Francisco Parent Study Since you came in to your last clinic visit,
launched the Healthy Beverage Initiative (HBI) in an effort to align campus Reward Based Eating Drive have you reduced the amount of sugary
policies with the growing body of literature regarding the negative impact of
§ Nested sample of drinks that you drink?
excessive sugar consumption on health. UCSF is the first university that • The RED scale, measures vulnerability to reward-based § Representative 214 heavy SSB 80
included both the campus and the medical center to ban the sale of SSBs.
eating behavior. Includes lack of control over eating, lack of sample of 2543

Embedded within the larger HBI study is a randomized trial of 214 UCSF drinkers 60
employees who report heavy SSB consumption at baseline (The Metabolic satiation, preoccupation with food (Epel 2014). UCSF employees Metabolic § Measures: body p = 0.0008
40 Control
Substudy). Within this substudy, participants were randomly selected to receive § Measures: SSB Substudy measurements,
educational materials and a motivational intervention. Both the control and Perceived Stress Scale intake & attitudes dietary data, 20 Intervention
intervention group participated in a clinic visit at baseline and a 10-month follow 0
up visit; at both time points, body measurements, dietary data, and blood draw, • Measures the degree to which situations in one’s life appear fasting blood draw
along with other measurements, were collected. For preliminary analyses, we Yes No
stressful (Cohen 1983).
analyzed the measures available at this time, which included beverage
frequency, waist circumference, BMI, reported stress and reward drive. The IF YES: How much have you reduced?
intervention group reduced sugary beverage consumption compared to those in Control Intervention 40
the control group (83.91% of intervention participants said they reduced,
61.36% of control participants said they reduced; p = 0.0008). For both the Aims 30

control and intervention groups, we saw a marginally statistically significant p = 0.1591
decrease in BMI, along with a decrease in waist circumference over the entire § Receive educational materials based on those 20 Control
metabolic substudy sample. The results from this study suggest that the 1. Determine if there are overall changes in physical from UCSF’s Sugar Science website, which
counseling intervention boosted the reduction of SSB consumption even (BMI & Waist) and psychosocial health indices (PSS describes the effects of sugar. 10 Intervention
further. It may be important to provide counseling for heavy SSB drinkers in § A copy of the video “Sweet Revenge” by Dr.
addition to policy level changes. There is some promise that a multi-level & RED) within the metabolic substudy. 0
intervention that includes changing the food/beverage environment and
Robert Lustig, describing sources of sugar in the Very little Little Stayed Mostly Complete
American diet and ways to reduce sugar intake. the same reduction
individual counseling may be more effective than policy change alone. 2. Determine if the intervention influenced health § 5-10 minute conversation with key personnel
indices and psychosocial measures within the about health goals and sugar consumption.
Introduction metabolic substudy. § The option to receive booster calls to report on
their goals and engage in problem solving. Conclusions
Liquid sugar is the single largest source of added
• Our data suggests that a sales ban on SSB’s may
sugar in the American diet. Growing scientific evidence
contribute to a decrease in waist measurement and a
shows that too much added sugar, over time, is linked
decrease in self reported sugary beverage consumption,
to diabetes, heart disease and liver disease.
Preliminary Data Intervention Effects
The mean change in anthropometric measurements and psychosocial
as well as a potential decrease in BMI, PSS, and RED.
outcomes suggest that the Healthy Beverage Initiative in combination with
Data obtained from the baseline clinic visit as well as the
• These effects seem to be even more pronounced when the
the intervention was even more effective at decreasing measures of adiposity.
The Healthy Beverage Initiative follow up (10 months post).
Although we see trends toward a decrease in BMI, Waist, PSS, and RED,
sales ban is combined with a counseling intervention.

What? UCSF eliminated the sale of sugar sweetened beverages none can be attributed to statistical significance. • If we can continue to show significant changes in the
BMI Perceived Stress overall health of employees after a sales ban this may
32 15.65
When? Began July 1, 2015 & was completed November 1, 2015 Change in Anthropometric Measurements encourage further research, and other medical institutions
BMI (kg/m2)

and campuses to adopt a similar policy.
Where? All vending machines, cafeterias, campus eateries and 15.60
30 -0.5
retail locations. All catering services and even patient menus.

NOTE: Not a “BAN” – anyone can bring SSB’s to UCSF
p = 0.089
Future Research
p = 0.084
28 15.50 -1.5 Differences in SSB consumption may be due to
Acceptable Beverages Under HBI Baseline Follow Up Baseline Follow Up -2 sociodemographic factors. Considering the disproportional
Smart Choices: Contain no added sugars and no artificial -2.5 impact on the socioeconomically disadvantaged would have
sweeteners Reward Based Eating enormous implications in improving the health of our
Waist Circumference -3
o Still water, flavored water, sparkling water, unsweetened Drive community.
99 -3.5
ice tea, unflavored milk, hot coffee and tea 0.1 BMI Waist
Waist (cm)

Other Alternative Choices: Contain no added sugars but may 97 0.05 Change in Psychosocial Outcomes
contain artificial sweeteners
96 0.6 Dr. Elissa Epel, Dr. Cindy Leung, Alison Hartman, Samantha Schilf,
o 100% fruit juice, diet/zero-calorie soda, diet iced tea, diet Julia Clark, and May Szeto from University of California, San Francisco.
sports and vitamin drinks 95 0 0.4 Lynne Arcangel, UC LEADS at University of California, Davis.
Baseline Follow Up Baseline Follow Up
Refrigerators at UCSF 0.2
p = 0.337 p = 0.148
Laurel Heights post-HBI.
Note: All drinks are diet
Measurements Psychosocial Outcomes
Control References
or sugar free. -0.2 Intervention
We saw decreases in both mean BMI Both PSS (p = 0.880) and RED Cohen, S., Kamarck, T., & Mermelstein, R., "A Global Measure of Perceived Stress." Journal of Health
(p = 0.076) and waist circumference (p = 0.871) decreased over the 10 -0.4 and Social Behavior, 24 (1983), 385-396.

(p = 0.001) over the 10 month period. month period, although the Epel, Elissa S., A. Janet Tomiyama, Ashley E. Mason,… and David Kessler. "The Reward-Based Eating Drive
The difference in waist is statistically reductions were not of statistical -0.6 Scale: A Self-Report Index of Reward-Based Eating." PLoS ONE. Public Library of Science, 2014. Web. 20
July 2016.
significant, whereas the change in BMI significance. Perceived Stress Reward Based Eating
is marginally significant. Scale Drive Malik, Vasanti S., Matthias B. Schulze, and Frank B. Hu. "Intake of Sugar-sweetened Beverages and
Weight Gain: A Systematic Review." The American Journal of Clinical Nutrition. U.S. National Library of
Medicine, Aug. 2006. Web. 20 July 2016.