In April 2021, two teams of ProSPER members participated in the National Science Policy Network‘s policy memo competition. This is the memo by Adrienne Brauer, Ananya Benegal, Kayla Hannon, Jessica Kuppan, and Sarah Speck; the memo by Hannah Frye, Daphne Ko, Emilee Kotnik, and Nathan Zelt can be found here.
The city of St. Louis, Missouri has excessively high rates of maternal and infant morbidity and mortality, with Black mothers and infants 2 to 3 times more likely to experience adverse outcomes than White women. Factors such as obesity and heart disease play a large role in pregnancy complications, and access to nutrition in St. Louis also diverges along racial and socioeconomic lines. Cheap and easy access to soda and other sugar-sweetened beverages (SSBs), combined with travel barriers and prohibitive costs of fresh produce, make it difficult for residents to maintain healthy diets. To combat these issues, we recommend a two-pronged approach: (1) impose St. Louis City and County taxes on sweetened beverages at 1.5 cents per ounce, and use the revenue generated to (2) establish fresh produce food trucks to deliver low-cost groceries to residents in food deserts. Implementing these policies has the potential to both decrease the consumption of excess sugar, as well as increase the access to and affordability of fresh, nutritious produce. These changes will encourage a holistic improvement in the diet of St. Louis mothers and families to prevent adverse pregnancy outcomes.
Statement of the Issue
The city of St. Louis and state of Missouri have some of the worst maternal and infant mortality rates in the country (Centers for Disease Control and Prevention 2021). Further, Black women in Missouri are 2 to 3 times more likely to die from pregnancy-related causes than White women (Centers for Disease Control and Prevention 2019), a disparity that exceeds national rates. Major risk factors for poor maternal and infant health include maternal obesity, diabetes, and heart disease (Centers for Disease Control and Prevention 2020). Lifestyle interventions to improve both maternal and infant health should ideally occur prior to pregnancy. High blood glucose during conception is linked to congenital malformations, meaning that the typical second-trimester screen for gestational diabetes is too late for many babies (American Diabetes Association 2021). Diabetes is strongly associated with obesity. Unfortunately, the obesity epidemic disproportionately affects minorities. More than half of U.S. births in 2017 were to overweight or obese women, including nearly two-thirds of births among Black and Hispanic women (Martin et al. 2018). Among Missouri residents, more than one in three Black women are obese, versus just one in four White women (Missouri Department of Health and Senior Services 2020).
Poor nutrition contributes to the prevalence of obesity and thus to poor maternal and infant outcomes (Zhang et al. 2019). 56% of St. Louis residents live in food deserts (i.e., low-income neighborhoods with low access to healthy foods within walking distance) (USDA 2021). The geographic distribution of food deserts in St. Louis demonstrate clear racial disparities; 70% of Black residents in the city of St. Louis live in low-income, low-access neighborhoods (Missouri Coalition for the Environment: Food Access). Black residents are also more likely to live in poverty and do not have sufficient living wages or transportation access to buy healthy foods in their area (Missouri Coalition for the Environment: Intersectionality).
Excessive calorie intake contributes to obesity and diabetes, primarily from overconsumption of sugar-sweetened beverages (SSB) such as soda and energy drinks. Although added sugars should constitute less than 10% of caloric intake according to World Health Organization (WHO) guidelines, American women of reproductive age surpass this limit by more than 50%, regardless of pregnancy status (Lundeen et al. 2020, Cioffi et al. 2018). St. Louis City and St. Louis County residents consume an average of 1.5 SSBs per day (Pipito et al. 2018). Given that there are 3500 calories in 1 pound of body weight, if an adult drank an extra 12-oz can of soda every day, that person would consume more than 50,000 extra calories in a year and could gain almost 15 pounds (Guth 2014).
To most effectively combat maternal obesity, which confers a risk of heart and metabolic disease to offspring, research suggests emphasizing obesity prevention through dietary modifications and lifestyle interventions (Hanson et al. 2017). An impactful way to improve maternal and infant outcomes would be to implement (1) a sweetened beverage tax and (2) fresh produce food trucks, in effect converting caloric intake from added sugars to natural sugars and dietary fibers.
Option 1: Implement a St. Louis City and St. Louis County sweetened beverage tax.
We propose a sweetened beverage tax aimed at both (A) curbing obesity and (B) raising revenue for future public health programs. Separate local governments oversee St. Louis City and the neighboring St. Louis County. We propose amending the St. Louis City Code of Ordinances, Title 8 to add a new Chapter; and the St. Louis County Code of Ordinances, Title V, Chapter 502 to add a new Section, “Beverage Tax,” establishing a 1.5 cent/oz sweetened beverage tax. Taxed beverages will include those consisting of caloric and/or artificial sugars. Beverages will be taxed at point-of-sale by retailers, with taxes paid to the St. Louis City Collector of Revenue or the St. Louis County Treasurer, and allocated to an account specific for public health programs.
Advantages of Beverage Tax
A 1.5 cent/oz beverage tax has the potential to raise more than $50 million annually across the city and county. This projection assumes that the average St. Louis adult consumes just 1 SSB/day and that each beverage has 12 oz. A sweetened beverage tax in Cook County, IL, raised $61.6 million in revenue in just 4 months (Powell, Leider, and Léger 2020). Such a tax in St. Louis has the potential to deter consumption away from unhealthy beverages and improve population health.
The WHO endorses taxation of sugar-sweetened beverages to curb obesity. In order to prevent excessive sugar consumption, multiple municipalities have implemented sweetened beverage taxes, including Seattle, Philadelphia, Berkeley, and Boulder (Seattle.gov, City of Boulder). A 1-cent/oz sugary drink tax in Berkeley decreased SSB consumption by half in just 3 years, starting in 2014 (Lee et al. 2019). A similar tax starting in 2017 in Philadelphia (1.5 cents/oz of sugar or diet drink) reduced sweetened beverage consumption by a net of 22 to 38% (Seiler, Tuchman, and Yao 2021, Roberto et al. 2019).
Disadvantages of Beverage Tax
A local sweetened beverage tax may disproportionately affect families of low socioeconomic status, who make up a significant proportion of consumers and who may lack the transportation to purchase these drinks outside the regional boundaries of the tax (Colchero et al. 2017). However, the cost of these taxes will deter overconsumption of added sugars and increase public awareness about healthy eating, helping mothers and their families choose heart-healthy diets in these low-income areas. For other residents, city-based beverage taxes may increase soda sales outside St. Louis City, drawing away tax revenue. Nonetheless, net soda sales are still reduced even after accounting for cross-border shopping (Seiler, Tuchman, and Yao 2021, Roberto et al. 2019), suggesting that such a health tax may still improve the rate of sugar intake. To combat such cross-shopping, we propose that St. Louis City and St. Louis County present a united front against overnutrition by simultaneously implementing the beverage tax. Finally, similar taxes and legislation have sometimes been affected by objections to increased costs and restriction of personal choice. A beverage tax in Cook County, IL, lasted only 4 months in 2017 before it was repealed (Powell, Leider, and Léger 2020). However, Chicago used only 27.2% of their beverage tax revenue to fund public health measures, while cities like Albany, California used at least 74% to increase exercise and nutrition in the community (Lin and Fitts); a more robust plan to improve all-around health and convince constituents of the tax’s utility. Data from the Chicago area and Philadelphia demonstrate that these taxes still lead to an overall reduction of sugar consumption, but only while the taxes remain in place (Powell and Leider 2020).
Option 2: Use profits from the sweetened beverage tax to implement fresh produce food trucks to serve people in food deserts.
We propose the coordination of St. Louis City’s Health Equity Program and St. Louis County’s Department of Public Health, using profits from the sweetened beverage tax to purchase several fresh produce food trucks. In the County, this would be added as the “Fresh Produce Distribution Fund” provision under the St. Louis County Code of Ordinances, Chapter 620 (Municode Library St. Louis: Chapter 602). In the City, the program would be established as a vendor under the St. Louis Code of Ordinances, Chapter 8.108A (Municode Library St. Louis: Chapter 8.108A). These food trucks will be operated in a similar fashion as New York City’s Green Carts (Fuchs et al. 2014). Aided by a mobile food delivery model that takes into account the geography of our target customers within food deserts (Widener, Metcalf, and Bar-Yam 2012), food trucks will travel around St. Louis City and County providing affordable fresh fruits and vegetables sold at a financial loss. Selling produce at these prices will ensure accessibility for St. Louis residents. We propose distributing vouchers for low-income families, kids during summer months, pregnant women, and those deemed at risk of or diagnosed with obesity and/or diabetes.
Other cities have seen success with similar programs to increase access and affordability of produce, including Baltimore and Washington, D.C. (Santo, Yong, and Palmer 2014, Snelling et al. 2020). In St. Louis, there currently exists a non-profit called the St. Louis MetroMarket, which repurposed a city bus into a traveling produce market. Even with the limitations of a small non-profit startup, the company has delivered nearly 80,000 pounds of produce to 40,000 people (Berger 2020), proving that there is a need in the area. The fresh produce food truck program would establish a more extensive fleet of trucks that could reach a wider population at more frequent intervals and more locations.
Advantages of Fresh Produce Food Trucks
New York City implemented Green Carts in 2008 and saw a 71% increase in their customers’ fruit and vegetable consumption, and 63% of customers became regulars. The St. Louis initiative will focus on reaching low-income community members, which by definition are populous in food deserts. In addition, bringing produce to areas in need reduces the need for travel. This is particularly critical for the more than 20% of households in the St. Louis area without a vehicle (Flourish St. Louis). Furthermore, provision of vouchers and easy access to fresh produce are readily welcomed by residents of food deserts, including Baltimore and Washington, D.C. (Snelling et al. 2020, Gudzune et al. 2015).
Disadvantages of Fresh Produce Food Trucks
To maximize feasibility, food trucks will likely not operate every day of the week, which limits produce availability. Furthermore, resources and money will need to be allocated towards multi-pronged communication methods (website updates, email notifications, mailed flyers, word of mouth), to ensure information on the food trucks’ schedule and location reaches our targeted customers. Lastly, the pricing of produce will depend on the revenue of the beverage tax and therefore could periodically alter costs.
We recommend incorporating both the sweetened beverage tax and fresh produce food trucks in tandem to achieve the greatest nutritional benefit for St. Louis City and County constituents. These complementary recommendations aim to reduce dietary intake of low-nutrient beverages and increase intake of highly nutritious alternatives. We anticipate that simultaneous implementation of these programs will improve nutrition among mothers and families of low socioeconomic status, promoting metabolic and cardiovascular health in under-resourced communities for years to come.
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