1. Vending Machines and Health Systems Controversies and Concerns Diane Dooley MD

2. 12/08/09 2 Obesity is on the rise Percent overweight and obese Contra Costa County children 2 – 19 years Pediatric Nutrition Surveillance 2008

3. Contra Costa children ages 5-8 by ethnicity Pediatric Nutrition Surveillance 2008 Health Disparity Emerges

4. Vending machines in hospitals 7% of all US vending machines in hospitals and nursing homes California laws do not regulate nutritional content Profit pressures correlate with quality Beverage vending agreements vs. food vending agreements

5. Vending machines at CCRMC Patient access machines located in Richmond, Pittsburg Health Centers, CCRMC cafeteria Unknown profit No contract County provides electricity, space, disposal of waste, associated cleaning costs

6. Vending machines standards County Healthy Vending policy passed 2004 50% Healthy drinks, snacks Public health audit 2007- 20% compliance Best selling items: Cheetos, Doritos, Lays Classics, soda, candy

7. Vending Machine survey Smart Choices are marked by green star Most survey participants did not notice the smart choices posters on the machines ½ of Spanish speakers thought green stars meant item was cheaper Majority had purchased items from the machines in the last few visits

8. Pittsburg Health Center They are often eating chips in am clinic visits

9. Pittsburg Health Center 43.7 of Fifth graders are overweight Pittsburg Unified School District 5 th graders Healthy Kids Survey 2006 Pittsburg Unified School District 5 th graders Healthy Kids Survey 2006

10. Obesity Efforts Pittsburg Health Center 80% of providers report counseling almost all patients to avoid sweetened drinks Soda Free Summer campaign Prenatal Sweet Success program Diabetes registry Pediatric Obesity QIP FIT resident grant NEW Kids program

11. Obesity Efforts Pittsburg Health Center WIC social marketing campaigns Have Fun and Be Healthy Have Fun and Be Active Healthy Drinks New food package introduced October 2009: More breastfeeding support Less juice More fruits and vegetables New food package introduced October 2009: More breastfeeding support Less juice More fruits and vegetables

12. 12/08/09 12 Soda – Should we sell it? Increases likelihood of being overweight or obese Density of fast food restaurants and convenience stores correlates with obesity and diabetes Highest consumption among children from low income families, Latino

13. 12/08/09 13 Soda – Should we sell it? Concord 44.2 Richmond 46.1 San Francisco 36.9 Bakersfield 60.1 49% of California children consume one or more sweetened soda daily Childhood consumption increasing annually Soda, fruit juice and sweetened beverages provide an average of 270 extra kcal/day (10-15% total) Percent of Children and Adolescents 2-17 years drinking one or more sodas per day

14. 12/08/09 14 Health impacts for children Dental caries associated with frequent consumption of sugary foods Higher rates of fractures, osteoporosis Highest risk groups: low income, Latino, African - American, uninsured

15. Snacks 170 Calories/11 grams fat/serving 120 calories/ 20 ounce bottle 280 calories/ 14 grams fat/serving

16. Sweetened Drinks survey 100% of health professionals surveyed felt sweetened drinks were a problem Most providers discuss the harmful effects of sugar and sippy cups Inadequate time, parental disinterest and easy access to junk food limit counseling effectiveness Culturally appropriate tools and vending machine restrictions would assist providers in addressing this issue

17. Counseling Patients Barriers Top Five: Parental disinterest/overwhelm in setting limits for children Parental disinterest/overwhelm in promoting health Lack of adequate time to counsel Lack of culturally relevant, up to date educational materials/counseling tools Awareness that families may not have the resources to buy healthy drinks

18. Food Marketing to Children Constant assault of marketing these drinks to kids makes me a voice in the wilderness A study of McDonalds restaurants in Childrens Hospitals showed correlation with increased fast food purchasing by parents and a more positive perception of the healthiness of McDonalds food...food and beverage marketing influences the preferences and purchase requests of children-IOM

19. Department of pediatrics worked with Public Health and CCRMC dietary department in 2008 to develop 100% Healthy vending policy Based upon SB 965, SB 12 School standards Passed by MEC as part of the pediatric obesity quality improvement initiative October 2008 Implemented by CCRMC cafeteria vending machines October 2009 100% Healthy Vending Policy A supportive environment helps individuals make positive behavioral changes and models the importance of healthy lifestyle choices for patients and families

20. Nutritional Environment Food environment may influence health and nutritional choices Formula and the perinatal unit, Cigarettes and smoking at health centers Make the healthy choice the easy choice

21. Conclusion Vending machines in clinics provide convenient foods to patients and profit to the health system. Providers in the clinic are actively educating patients about the hazards of soda and unhealthy snacks but feel undermined by the presence of machines in the lobby selling junk food Our health system should move towards a 100% healthy vending policy in all patient access machines and model a healthy nutritional environment our patients