so, if you just focused on the statistics at the city level, you will miss the health and equities that in our city. that's really important to dig down and see the differences. ~ health inequities these are statistic that everybody is already familiar with. so, i won't go over it. it's just a distribution of the ethnic population in san francisco and some of the changes from 1990 to 2010, and the dynamic population, it continues to change. the first thing i want to point out here, now, this is -- this is data looking at adolescents and this is now in san francisco broken up between children on the left-hand side and adolescents on the right-hand side. what we do notice is that from 2005 to 2007, that there has, there has been a decrease in sugary drink consumption among

children 2 to 11. and, so, our interpretation of that is the impact that's having and educating parents about decreasing sugary drink consumption among young children. unfortunately, when the kids reach the age like my children and they have access to the environment where sugary beverages are readily available, we can see in the most recent data, 2011 to 2012, we've had an increase in sugary beverage consumption among all youth across all ethnicities. the next slide points out, this is now looking at children and adolescents you can see in two or more glasses of sugary drinks by ethnicity. and what you can see here is that for latinos and asians, they actually drink more sodas. the reason why african-americans are not shown here is because the california health interview survey, but the use he of researchers will show you that they also have

higher levels of soda consumption compared to whites -- >> skew me, review that one more time. >> the california interview survey because the way that's designed and the size of the african-american population in san francisco, we don't have a specific data, but we know from other data, when you look at the broader area african-americans do drink more soda. ~ excuse so, they'll be similar to, for example, latinos. the other thing we notice, this is data from the san francisco unified school district looking at fifth graders, seventh graders and ninth graders socioeconomic status. that if they're economically disadvantaged, they're 60% more likely to be overweight for these children. and we see this throughout california and throughout the united states. so, being low-income, you're more likely to be overweight and obese. these other slides are not going to be a surprise, and

that is if you're a soda consumer, you tend to be overweight. and as i already mentioned that latinos and african-americans consume more sodas and we see more overweight in those ethnicities. when we look at adults, we see the same. if you're a soda consumer, you tend to be overweight and this is, again, true for african-americans and latinos having the highest rates of both soda consumption and being overweight. so, throughout the united states, california and in san francisco, we've had, we've had increases in the rates of diabetes. now, diabetes, about a third of people who actually have diabetes don't even know they have diabetes. we know that diabetes is going to lead to heart disease,

stroke, amputations and sections. a colleague of mine a few weeks ago, we were talking about when we used to take care of aids patients onward 5a in san francisco, and we were -- >> san francisco general hospital? >> san francisco general hospital. and we were commenting, he was commenting on how ward 5a was full of patients with aids. he says today it's full of patients with complications from diabetes. we know right now data that's just released a few days ago that a third of the hospitalizations in california are due to diabetes and we see that also in san francisco. here we see among african-americans, this is from the california health interview survey, that about almost 12% have -- will have reported having diabetes and we see high rates also among latinos. one thing i want to point out, one thing i want to point out is that the lifetime risk, the

lifetime risk is going to be closer to 50% for african-americans and 30% for latino. the lifetime risk is incredibly high. >> lifetime risk for -- >> for developing diabetes. and in san francisco, we see, for example, we see here the hospitalization rates for diabetes by ethnicity and we can see that the highest rate is among african-americans. what i want to do, before i turn it over to the other speakers, you will be receiving more detail. i just want to briefly just summarize how do we remember most of what i just said. so, we use this memory aid to help people remember. we call it sugar madness where the car is sugary drinks. the diagnoses is mad and the treatment is ness. sugar madness. metabolic dysfunction, the reason why metabolic

dysfunction is really important is that you can have the effects of sugary drinks developing metabolic dysfunction and putting you at risk for all those diseases, but be normal weight. very, very critical. you can have normal weight and be at risk for diabetes, heart disease, hypertension, bad cholesterol, all those thing. you do not have to be obese to have the adverse effects of drinking sugary drinks. the a stand for adipose for fat deposition. it's deposited in visceral fat and the liver that leads to the meted boll i can dysfunction. and then there are all the diseases that we now know are independently associated with sugary beverages ~ like diabetes and heart disease. so, the rising burden of disease throughout the -- in san francisco in increasingly due to sugary beverage consumption.

is ~ the treatment is to change condition, change sleep and exercise. i want to briefly go through the -- this slide here. in this slide here, this is part of changing -- this is part of changing the environment. this is what we're up against. this is an example of two billboards. in the top is a bill board saying childhood obesity, don't take it lightly. they're communicating to the parents in the neighborhood to take obesity seriously and right below that bill board we see mcdonald's saying, my kind of shopping with a very happy person who looks normal weight. so, this is a challenge that, that ethnic and low-income communities face, is that the industry reaches out to them and tries to get them to buy their unhealthy foods. so, what i'm going to do now is i'm going to turn it over to dr. jody stoky from internal

child health san francisco public health and she's going to give an overview of oral health. >> great, thank you. dr. stoky. >> hello. is there a way to pull up my presentation? >> do you have overhead presentation? >> presentation. >> sfgov-tv, we have a powerpoint. >> thank you. >> i'm all good from here. all right, sorry. okay. so, i am jody stukey from [speaker not understood], and thank you for your interest in this topic. i'm here presenting on behalf of staff from sfdph dental services and mch.

these programs provide oral health screenings every year to all the kindergarteners in the school district. so, i'll be showing you data from these screenings that show us that oral health disparities in san francisco correlate to sugar sweetened bergmanvxes. we have oral health disparities by zip code and income. we check to see if these correlate with sweetened beverages because the reduction, the reduction and consumption of thea beverages is a recognized strategy to reduce dental disease and we wanted to know is this relevant in san francisco. so, we know if sugar sweetened beverages are causing carries, we can see carries happening with obesity because these befogs have dual effects. this is a little different from other factors like having a dental health where you don't expect to see the carries. carries risk in san francisco is clustering with obesity.

starting with the data, san francisco is [speaker not understood] 18 million gallons of sugar beverageses each year, including 8 million gallons of soft drinks. we don't have these beverages in san francisco, it's a present exposure. the exposure is unevenly distributed across the city and certain neighborhoods in the tenderloin, in the mission, bayview, excelsior and visitacion valley. this slide shows carries experienced in kindergarteners by neighborhood. and you can see a very similar pattern. looks just like the pattern of beverage distribution. children in chinatown and southeast san francisco are more likely to have carries experienced than children in other neighborhoods. in chinatown, 50 -- >> i'm sorry, when you say more likely to have carries experienced, -- >> carries experienced means they have had a carry. >> what's a carry? >> a cavity.

so, they either have an active untreated cavity or they've had one that's been filled. >> okay. >> so, in the screeners, dental health professionals go out and they see either something active that needs treatment or something that's been fixed, that counts as a carry experience. so, in chinatown 50 to 60% of the kindergarteners have had an experience as cavities. the southeast parts of san francisco, 40 to 50% of the kindergarteners have experienced cavities. and these differences we see by neighborhoods are effective in ethnic and income disparities. asian, hispanic and black children are more likely to have carry experienced than white children. they're about two times more likely. lower income children are more likely to have carries experienced than higher income children. again, about two time more likely. this last data i'm going to show you shows the variation in carries experienced across the school.

so, each orange bar represents the proportion of kindergarteners that has experienced -- have had carries in that school. so, all the way on the left you have a school where 11% of kindergarteners that had carries experienced and all the way to the right you have a school where 90% of the kindergarteners have experienced carries. in this school district there are 22 schools where over half of the kindergarteners have had carries. in these schools where over half of the kindergarteners have had carries, we see that over half of the fifth graders are overweight. the bars on the bottom are indicating which schools have a very high prevalence of overweight. >> so, this, this picto graph doesn't define where the schools are? >> no. we have that information, but i didn't, yeah. >> we can only take so much bad news. >> i also wanted to remember to say that the data we have here, the carries are identified by

dental health professionals on all the kindergarteners and the way that is measured by the fitness gram requirement. unless a child is absent on the day they're doing this measurement or has an iep or to some reason exclusion that exempts them, these are all the kids that are measured. so, in sum, the pattern of carries of risk in san francisco reflects the distribution of sugar sweetened beverages. carries, risk and obesity are happening together. so, we have evidence of oral health disparities in san francisco are correlated with exposure to sugar sweetened beverages. thank you. >> great, thank you. i think we have another speaker. are you dr. -- >> [speaker not understood]. >> perfect. thank you for coming today. >> thank you for having me. let's see if i can figure out the way to load this.

>> my name is [speaker not understood]. i'm an oral maxillofacial surgeon at ucsf. i graduated from harvard medicine in 2008.

i practice in hospitals and community health centers primarily treating lower socioeconomic status patients for a few years and then went back to harvard school of public health to die masters in public health with specialized in community health. and currently i'm working on a community health project through ucsf and i'm going to talk a little bit about sugar sweetened beverages and the impact that i'm seeing. so, i think we've talked a bit about what they are, sodas, juice punches, powdered drinks, et cetera. a fair amount of sugar in a single can of coke has 10 teaspoons of sugar -- >> doctor, do you have -- do you have a printout of your presentation? >> i don't have a printout, but i can provide you with -- it's up on the screens here. >> i know it's on the screen. [laughter] >> i know that. thank you. so, i would like to get a copy of it so we can have it in the file for public record. >> it will be my pleasure. >> okay, thank you. >> sorry.

>> it's okay. >> so, a single can of cola has more than the maximum recommended daily amount of sugar that we should consume and we certainly know that it only goes up from there. at least 7/11 sort of taking the cake on over 100 teaspoons in their largest offerings for cola. so, dr. aragon very elegantly outlined sort of in the body physiology for how sugar sweetened beverages affect health outcomes, specifically changes in the liver. also confusing our bodies into thinking we actually haven't consumed that many calories. but the other part of science that actually matters is not just what is sort of the theoretical impact, but rather when we take people who don't have disease and we expose them to sugar sweetened beverages and we have another similar group of people that we don't expose to that, do we see the health outcomes happen. and the answer is yes in a

statistical way. we have several studies that have been done on that. the nurses health studth i is a great, what's called the cohort study that's following groups of people for decades and we see incidence of diabetes primarily in women there. several studies that are looking at diabetes and not just in the american population for the nurses health study. the framing ham studies, studies in singapore, in china, for several different studies basically you take similar people, people who do drink sodas and sugar sweetened beverages and people who don't do that and you see diabetes in people who do, statistically significant more so than if they don't. also we know that through the same types of studies, it causes increase he in weight gain. we see those. and then we talked a little about the physiology of high fructose corn syrup.

we've really vilified high fructose corn syrup. take out the corn syrup and put sugar and that's not going to help. physiology has things that do affect the liver. but it's all sweetened beverages do the same thing as far as changing our metabolism, making us at higher risk for strokes, heart attacks, and then what about dental carries. so, the question is is it just diet or is it diet and hygiene and what about fluoride, too? so, you take people in a fluoridated community with access to fluoridated tooth paste, using them all the same time, and you say who are the people drinking sugar sweetened beverages and who are the people not and do they get cavities over periods of time. turns out in children and adults the answer is yes. so, you know, there are several things that influence all these disease processes and it's important for us to address many different causes of

chronic diseases, it turnout sugar sweetened befores are part of that approach. some of the science, sugar sweetened beverages do play a significant and measurable role in the development of obesity, diabetes, cardiovascular disease and dental decay. there are several other areas being actively explored. but reduction of sugar sweetened beverage consumption plays an important part in reducing the burden of disease. what about sort of a short list of reputable organizations who think this is true. the american beverage association reminds us things like, all beverages provide hydration, another such true but not really relevant facts on their website. so, what are we going to next? next? what about in san francisco, what are the neighborhood based disparities? my colleagues have talked about soda expenditures by district. we know that the poorer neighborhoods tend to consume more soda. we know that -- here is a chart of residents

drinking soda daily. we also see actually quite a bit in my neighborhood the sunset there. but what about diabetes hospitalizations? really, in that same region we're seeing quite a bit there. i'll actually speak quickly on -- i actually work in oral maxillofacial surgery clinic in san francisco general and in children in san francisco, which is where most of our data on dental carries, the process that causes he cavities, we actually care about that ~ and we measure that. it turns out in adults from a policy standpoint for some reason, people don't care. and i had a visiting oral surgeon from england come observe with me in our clinic and all these people are coming in with big holes in their teeth and he he asked me, why don't they go to the dentist? apparently in america we don't care about that. we don't think that's important. we just let it get bad enough to where the tooth can't be fixed any more and that risk

for bad infections. i've had people in the intensive care unit i've taken into the operating room and had to drain their necks and sugar is a big part of what is causing their disease. what do we do, how do we change behavior? education is great. i believe my student loan debt shows that i care about education. [laughter] >> so, it's an important component of what we do, okay. so, we have several things -- there's the bigger picture.org which has online videos and curricula, school-based workshops on healthy diets, shape up san francisco's education campaign looking at billboards, looking at community based workshops, getting the word out is important. but it turns out it's not enough. and lots of studies have been kind of looking at this for years and years, don't smoke, smoking is bad, don't smoke. i know, i know, but here it is. then you make it more expensive, oh, my gosh, i have to smoke less. it's costing me too much. use less gas, you know, gas is

limited. oh, how much -- how much did your car have? 2008 gas prices went up and suddenly it's cool tao about your mile per gallon. turnout changing the price per gallon is important. here are a couple things. education alone is great, but doesn't change behavior that much until the individual decision maker is actually faced with something that changes the way they make the decision. what we need to do as a city is to make the healthy choice the easy choice and the affordable choice. so, what the institute of medicine says is do it from several different approaches. one is tax strategies. so, basically place a tax on the things that are causing disease and when we do that, a, we build revenue from those taxes which can go back into the research and the treatment of the sequela of the causes of these chronic diseases. and all we can do is adopt land use and zoning policies to

restrict the number of fast food establishments around school grounds and public play grounds. we saw that the adolescents are really drinking a lot of sodas, sugar sweetened beverages because they suddenly have a little bit of money in their hands and they can make decisions with it. when you take someone with a small amount of money and you make a change in price, you actually get a change in behavior. and then limiting the number of advertising and marketing things that can be done around schools and basically create incentive programs, again, to make healthy choices affordable and very accessible to adolescents around schools. so, in summary, sugar sweetened beverages are unhealthy, but actually is true. if you have questions about the science, i'm happy to field them. reduction in sugar sweetened beverage consumption reducies several diseases both in terms of financial and social capital

and education campaigns, policy approaches that incentivize healthy behaviors, discourage unhell healthy behaviorses and raise revenue for the city, do so without restricting choice ~. in new york city they tried putting bans on very large sugar sweetened beverages. that's not what we're saying. we're saying make the healthy choice the easy choice. make the healthy choice the affordable choice and people will change their behavior. thank you. >> great, thank you. any questions, colleagues? okay, seeing none, thanks for your presentation. and our final presentation is from dr. christin bivens domingo. okay, carolyn. >> [inaudible]. [laughter] >> sore, this is dr. carolyn brown from the san francisco community clinic consortium. do you have a copy of your presentation as well? >> i do not. >> can we have a copy for the file for the clerk?

>> i certainly will do that. >> okay, thank you. >> good afternoon. my name is carolyn brown. pardon my [speaker not understood]. i'm the chief dental [speaker not understood] for the san francisco community clinic consortium. i was also the dental director for the native american health center in the mission district for the past 13 years up until about a week ago. and the dental safety net in san francisco works very hard to try and address all of the dental decay in our city. however, it continues to be one of the highest unmet needs among any type of vulnerable population polled or evaluated in this city. [speaker not understood] exposure to unhealthy diet and sugar sweetened beverages.

so, san francisco community clinics partners see about 38,000 dental patient visits per year and it's all in the low-income and minority patients. all of our centers are located in the neighborhoods that were previously described by my colleagues and really we're the people who can tell you on the ground what we see when we look in the mouth. tooth decay is something that is often called the silent epidemic by the surgeon general and it's really the number one chronic disease in our chill chren in this country. it's 10 times more common than asthma, seven-time more common than allergies and the health disparities are staggering in low-income people in this country. [speaker not understood] multi-spectral disease which is why a vaccine is available for [speaker not understood] because part of what happens with dental decay, the nutritional and home health behavior is a hygiene pieces, community health [speaker not

understood]. it is almost completely preventable. unlike a lot of other diseases that you see and hear about taking good care of your teeth, changing your diet and really, you know, incentivizing patients to be able to take care of their choices and their health is something that can actually positively affect health outcome in the mouth. and it is extremely high and prevalent across the country. around 92% of adults in this country between the ages of 20 to 64 have experienced some form of dental decay. so, sometimes we look at dental decay as something that is bound to happen to us. and not thinking it's preventable. this is a quick pictorial on what happens with dental decay. basically you have a tooth and in the tooth is plaque, the things that [speaker not understood] you brush off when you brush your tooth or floss your teeth every day. the bacteria takes certain type of bacteria, opportunistic bacteria in the mouth that actually start getting active when we eat. and when you drink. it gets particularly active in

the face of high sugar content because it's what feeds it. it's its food source. this produces metabolic waste and eats away at your tooth. the problem with sugar sweetened beverages is that it make that bacteria incredibly active. it's not -- in many, many studies and we've looked at healthy normal and moderate sugar diets at one meal. afterward presented 20% of acid from the bacteria. 20 minutes bad bacteria is starting to try and invade the tooth. in the presence of sugar sweetened beverages that can last up to 60 to 80 minutes. we not only have bacteria that are much more active in the face of high sugar content, they're also active for a much longer time period. >> let me interject a question here. oftentimes in the discussion as it relates to sugary beverage there is a distinction between diet coke and regular coke.

in terms of the active production that sugar is stimulating the bacteria, does it make a difference if it's a diet coke versus a regular coke? >> well, i'm going to say no to that, supervisor cohen. more so because it's actually a two-pronged approach. one is the sugar, synthetic sugar or a naturally occurring sugar, there is a slight difference. if you look at, you know, bench test in a science lab on how active the [speaker not understood] which is the main bacteria involved in tooth decay is minor. but the biggest problem is that there is also huge -- the acid content of just a cup of any type of sugar sweetened beverage because an energy drink like diet coke or regular coke is incredibly acidic. ph of 2 and ph of 4. in general it has a natural ph. 7 is a neutral ph.

so, you're taking this acid-loving bacteria, giving them more acid regardless of the sugar, it become not just an additive. it is exponential in the mouth. it is particularly damaging in baby teeth because baby teeth are very, very thin. the aloe dynamically et, protective coating on baby teeth [speaker not understood]. ~ enamel children are drinking sodas. [speaker not understood]. it does speed the loss of calcium from the teeth which makes it more susceptible to decay in the future. sfb, the consumption for children and adults in this country and in san francisco is going up. the consumption of milk and other nutritious drinks or even water is decreasing. i was using the madness picture o