hospitals who are concerned about the future financial viability given to the explosion of diabetes. despite the claims and argues about sugary beverage tax is a regressive tax, it's a much higher tax that will affect these communities. this is a tax supported by scientific evidence by knowledge and i'm glad we have brought this forth with the board of supervisors. i look forward to hearing this. >> good afternoon, everyone, thank you for being here and thank you for caring enough about not only your health but there is health of san francisco. i want to get my thank yous out in case i'm not

able to sit for the entire hearing today. but i want to thank you for your hard work and diligence on this report. it is incredible on what you have done and we've heard the facts on what will be part of this year. hopefully by the end of this initiative, we will, our children will be spewing out facts and it is our goal to raise people's awareness and i want to acknowledge the unprecedented number of educators all the way down to the clergy and to the people that are adversely affected by sugary beverages. i'm excited because we have an opportunity to inspire other municipalities and other cities all across this nation to really take a hold of our health care. and

policy of the affordable care act, and the other half paying attention to our diet and the third part being exercise. we will hear the statistics which are staggering when you know diabetes is a preventable disease and the birth defects and what liquid sugar does to the body and it is preventable and it is our responsibility as policy makers and leaders and more important as people of san francisco to continue to provide healthy options for those folks that need them the most. it's no secret earlier supervisor mar laid out the statistics what we are dealing with the african american and latino and pacific islander

community. it's not just this body taking up the cause but leaders within the ethnic communities that are also at the table. finally we have statistics, support and data. this is going to be a very very interesting year i predict for 2014. so, mr. chair, without further a do, let's get into this. >> thank you. i want to thank -- from the american heart association that's been very helpful. margaret fisher from the department of public health and janet cord row and maryann. thank you. supervisor avalos did you want to make remarks? >> thank you, let's call our budget legislative analyst. thank you very much mr. bruce

oh. >> today we'll be presenting a report on the study of impacts of high consumption of sugar sweets and beverages for the city and county of san francisco. we have some slides if we can. i'm just going to briefly introduce the report and then amanda guma from our office will walk you through details and we have hammond smith who will also be available for questions. we were asked to prepare a scientific research on the health risks associated with the consumption of sugar sweet and beverages. that's largely pertaining to obesity and diabetes and taking a look at

the financial risk for the san francisco residents. we have prepared analysis that identify cost that the city and county itself incurs and then the population of the city as a whole incurs that is separate from the city. finally we are asked to review and report on policies explored and implemented by other cities either in terms of a tax on soda or other initiatives that have been under taken to address this issue. so that's the overview of the purpose of our report and now amanda guma will walk you through the details. >> thank you to hamilton smith for the work on this. >> thank you supervisors. as several of you have already noted there is extensive scientific evidence that we found in our research on the connection between consumption of sugary sweet beverages and

chronic conditions particularly diabetes and obesity. as the american heart association found, maximum recommended consumption of sugars per day, added sugars per day for women is 6 teaspoons and 9 teaspoons for men. the regular drink has 37 teaspoons. diabetes has increased and increase in rate of chronic conditions. the number of american adults of obesity has more than doubled and diabetes has doubled and the percentage for children has tripled over the past 30 years.

we want to better understand what those impacts are here in san francisco. using data that we found from the centers for disease control on prevention from 2010, we found there were 180, 955 obese adults in san francisco and 46, 999 diabetic adults in san francisco. those populations are not necessarily distinct. so there is likely overlap between them. according to the agency for health care research and quality, there is typically about a 54.8 percent prevalence of obesity in diagnosed diabetes. we applied that rate to our san francisco numbers to get a better sense of what those distinct populations likely are. doing that we found there are likely

83, 249 obese adults in san francisco and 46, 909 diabetic adults in san francisco. in order to measure the cost related to the consumption of sugar sweet and beverages and the health impact that causes, we have to understand a few different factors. so, the first is the direct and indirect cost related to that consumption. direct cost would be the cost of medical care that are directly related to the intervention. so inpatient visits, outpatient visits, drug care, etc. indirect cost are related to work force productivity. these include absenteeism which is sick leave and disability and presentism.

which while being present at work, people who are suffering with these conditions are less productive during the workday. additionally, we want to take our projections and take the final analysis and see how much of the cost is attributed to sugar sweet and beverages. we found two rigorous studies that developed, quantified the percentages to understand those cost projections. one is done here from the department of public health 2009 nexus study where they looked directly at the impacts in san francisco of consuming sugary beverage and they found 86 percent of all the cost related could be attributed to sugary sweet and

beverages. similarly there were reports from the department of public health of illinois that looked at the diabetic population and they found a number of 8.45 percent. this slide goes through some of the studies that we use to refer to in our methodologies from duke university, cornell, washington, american diabetes association and the county. cook county is in the chicago area. they did a study in 2010 looking at the diabetic population. as we look at the cost projections for the city of san francisco, we look at two different things. we look at what the city spends in direct health care provisions and services to the obese and

diabetic populations. we also look at what the city contributes to health care cost through health insurance, through the health services system for employees, retirees and dependents. because we use several different methodologies we developed three scenarios which are outlined and detailed in our report to estimate the cost the city is currently spending to cover medical care related to obesity and diabetes that is attributable to sugary sweets and beverages. we look at the total cost, direct cost and indirect cost. we used for the analysis that you see on the table in front of you, the most conservative methodologies. so one of the studies that we looked at recommends using a 10 percent total medical cost attributable

to obesity. the cost to treat obesity and the cook county study which we were just talking about references a 23 percent. of total medical cost. we apply that in a few ways. one is looking at the total direct cost of medical care that the city spends annually. for that we use the general fund subsidies for san francisco general hospital, laguna honda and healthy sf. the other two scenarios we were looking at the cost that the city of the employer contribution that the city makes to the health system annually and taking those percentages of a cost and the total medical claims that the city pays out. you will see from the tables that using the estimates, we found a range of

approximately $10.8 million in estimated cost the city makes for sugary sweets and beverage consumption. we also looked at how much not only the city pays but san francisco residents are paying for cost of sugary consumption. we looked to account for that prevalence of obesity and that diabetic population. we took that data from 2010 from cdc and applied that method ology in that way. we used the most conservative estimates we can find. these are looking at the annual additional cost per capita per both the obese

population and diabetic population and we add those up and apply the percentages of and we came up with a total of $148.1 million that san francisco residents are paying for the cost of excess sugary beverages. >> that's a conservative estimate and it would be much likely higher than that. >> that's a conservative estimate. in the report we include a higher afro -- projection which is $61 million. another rate, we weren't able to find any methodology to quantify that is

the risk to children. we think this is an important population to look at. as you can see on the table currently as of 2010, 32 percent of san francisco children were over weight or obese. studies show that 63 percent of obese children grow up to be obese adults. while those cost are not something we are experiencing now and we can't quantify now, if there isn't intervention into these children's behavior there is a cost the city would experience later. also notably ucla and the california health study in 2011 found another 18,000 san francisco residents that received diabetes or border line. >> 1 in 3 children are obese? >> that is correct. those are not included in our

calculations because they don't fit in those categories yet but we do think they are important numbers. the last piece of our report is -- >> with respect to children, i know that as discussed in the beginning in terms of children beyond obesity are children getting diabetes or prediabetes and we know that once someone whether you are a kid develops prediabetes you are on your way and we are hearing more and more about kids in high school having not just prediabetes but full on diabetes and when you speak to pediatricians and disadvantaged part of the city with prediabetes or full diabetes. it's stark. >> yeah. we found some

statistics that showed approximately 3600 cases of childhood diabetes diagnosed annually. >> can i just throw in another question. i know that robert from uc sf pointed it's not just diabetes and obesity but also liver damage and other health problems and you are not even tracking that. it's probably even a much bigger problem than the data that what you are showing. >> that is correct. there are probably a list of 10 chronic conditions that the scientific evidence pretty extensively can connect to consumption of sugary sweet and beverages that we didn't quantify the health impacts and foreman impacts and

those include cardiovascular conditions and toxicity. again, we believe the estimations that we are providing are conservative. the last section of our report we were asked to rook at other legislative sections of the state. we looked through the cities around the country. to date none of them have succeeded. in addition we looked at efforts in other states on the state level, we found many attempts and some really small excise taxes put into place but nothing significant yet has passed. internationally probably many ofu been reading about the recent effort in mexico which to date has been

successful. that is a tax on soda at $0.08 per liter in addition to a 5 percent sales tax on other junk food. we will be watching that progress. in terms of the united states, to state to date it has not been successful in this regard. that's the end of our report. we'll be happy to answer any questions. >> any questions? thank you. the next speaker is robert vargas with ucfs with the policy program. they have advised on the health impacts and he's here to respond to the report.

>> good morning. thanks for having the budget and legislative office prepare this report. we are happy to be a part of gathering this data and helping it to be more accessible to the rest of the folks in the city. we really think it's important that folks are wear of the health impacts of this particular product. we are also very interested in partnering with the city and the university to inform policy decisions and public health approaches and take a look at the most current research and we believe that we have some

highly qualified researchers at our university to help with that information. i think this is a really important report for presenting what is a very difficult issue without having all of this information is difficult to understand. this information is really helpful in doing that. also in addition to what's being prepared here there is a number of disparity. what often gets lost in the conversation is the fact that there is tremendous disparity with regard who is tools to -- to who is

impacted. for example, if we look at rates of over weight or obesity in san francisco, the african american community is higher impacted at 21 percent in the community at being overweight. multiracial folks are impacted at 68.2 percent, latinos and pacific islanders. it's important to take into consideration that more than one community is more impacted than others. the hospital rates by neighborhoods we'll see --

where i live, that is the bayview. for hospitalizations per 10,000 people, 18 and over, if we look at age adjusted hospital rates due to diabetes, it's 29.7. in the 94102, it's 22 .2 and you have communities where the numbers are much lower like 4.3, 5.5 and 6.3, etc. we are looking at higher numbers. did you have a question? >> i was scratching my head but not in confusion. i was thinking about my district about 94-1-12. >> 10.8. about mid-range. most recently we had an opportunity to take a look at some data that shows excels ior was at

the higher end with regard to consumption given the latest data. those rates may have gone up because the data is a couple years old. all of this said which is important information, we appreciate the budget and legislative analyst office preparing this report. >> can you tell me the data for the fillmore district, 94-1-15. >> that's 14.8 hospitalizations per 10,000 population per year. on the higher end i would say, all of this data is available at sf hip.org, san francisco health improvement partnerships. this is data

that's been prepared and presented by san francisco hospital counsel and sf hip is a sponsorship of counsel and ucfs and other participants. any other questions? thank you for your time. >> i had a question, from what miss guma and mr. smith looked at, are there other questions that we need to answer to help policy making? >> that's a great question. as i mentioned this is a huge you -- issue and so some things that i know i have heard from other scientist who have been in inquiring from me with regards to impact of sugary drinks, folks have brought to my attention with impacts on

oral health specifically with children in terms of oral health. we have tremendous oral health disparity in san francisco. we have a lack of access to dentistry especially those that will take government subsidized dental insurance. that may change. i know the center for health serves the portola and bayview and there is limited access there. we also know that immigrant populations in particular, asian and latino immigrant children also suffer much higher rates of dental carries or cavities. so being able to quantified the impact of sugar ary drinks on children's oral

health will help us get a better picture of broad impact of sugary drinks. the research shows us that sugary drinks are one of the greatest contributors to children's cavities what we call dental carries. >> thank you very much. i skipped over christina gupta who is senior health planner from the department of public health. >> thank you supervisors. so, i just wanted to give you a little bit of background this afternoon about why the public health field has been looking at sugary drinks as an issue. i wanted to start talking about what happens to sugar when it's

in our bodies. sugar suppresses our bodies ability to consume fat. our body is the first one -- do you have an extra copy of the pregnancy -- presentation that you are making? >> i will make copies. >> so it suppresses our ability to burn fat. so when we eat sugar in high quantities our body priorities first burning the sugar before it starts burning the food that you might consume with that drink. so let's say you have a frappuccino with breakfast and a bagel. your body is not going to start working on that other food. if you haven't fully processed that by the time you have your next sugary item.

that other food may not get processed and turns into fat in your body. next, the way that sugar is metabolized is different than natural sugars. it's often converted to fat in your liver. when it's consumed m large quantities and quickly it's metabolized by liver and converted to fat. as we heard that significant obesity and chronic conditions. it also alters our hunger response. so we think that we are starving when in fact we are not. that has to do with the hormone called leptin. it resides in your fat cells and signals to your brain when you are full. and people can develop leptin resistance much like you can develop insulin resistance if

you are diabetic. what happens then is your brain does not get the message from the leptin hormone that you should stop eating that you are full. you just continue to feel hungry and you want to eat more. i personally have experienced this. lastly sugar alters the reward center in our brains. similar to addictive substances like alcohol, cocaine and nicotine, sugar downloads the similar receptors in your brain and we develop greater tolerance of those substances and in the case of sugar we crave more sugar and it bgs a -- becomes a vicious cycle. i think it's fortunate understand -- important