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. Thats a conservative estimate and it would be much likely higher than that. Thats a conservative estimate. In the report we include a higher afro projection which is 61 million. Another rate, we werent 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 cant quantify now, if there isnt intervention into these childrens 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 dont 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. Its 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 its not just diabetes and obesity but also liver damage and other Health Problems and you are not even tracking that. Its 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 didnt 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. Thats the end of our report. Well 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 hes 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 its 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 whats 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. Its important to take into consideration that more than one community is more impacted than others. The hospital rates by neighborhoods well 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, its 29. 7. In the 94102, its 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 94112. 10. 8. About midrange. 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, 94115. Thats 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 FranciscoHealth Improvement partnerships. This is data thats 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 . Thats 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 childrens 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 childrens 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 its 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 lets say you have a frappuccino with breakfast and a bagel. Your body is not going to start working on that other food. If you havent 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. Its often converted to fat in your liver. When its consumed m large quantities and quickly its 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 its fortunate understand important to understand that. When you take a look at the food system, sugar is really all over our food system. And as was mentioned previously about half of those sugars come from beverages. When you take a look at the beverages, soda contributes to the added sugar in our diets. When you calories from beverages that we drink often dont displace the calories that you might eat. So you will add those calories next to that burger and fries and again it has to do with your if physiological response where a drink may make you feel hungry. And from an environmental perspective when you look at the setting we are living in when mcdonalds introduced its first coke was 7 ounces and now you can go to 7eleven and get 128ounce gulp. You can also take a look at pricing and the prices for healthy food and fruits and vegetables have south courting according to the Consumer Price index and coupled with the fact that your body craves it, its something of an important dynamic thats going on here. We can see that over the decades as soda consumption has increased so has childhood over weight. You can see that correlation here. We are really pleased to see this is newer data from the california for Public Health advocacy showing consumption among adolescence and we have seen a decrease by younger children. Thats positive. I think some of the education efforts we have taken have made greater impact. However we have not seen that among older children. That is a concern that we have heard earlier. If you are over weight as a young person, there is a 63 percent chance that you are going to be overweight as an adult. What is the percent . 63 percent. Yes. Looking at local data, there is this slide that talks a little bit about the disparities in San Francisco that roberto spoke to. Here we are looking at ninth graders, African Americans and latinos. We see this translated down to San Francisco. Its not Just National data. We see this also among our adults and with the latino and African American populations that consume more sugary drinks. Can i ask about adolescence. Its my understanding that a ucla study shows slight decrease in younger children but in adolescence there has been an increase in Energy Drinks and marketing are tied in with a lot of the types of sugary beverages. Can you touch a little bit on that . Yes. I think its part of the environment that children are in and as an adolescence you are going to have more independence and more pocket change. The industry does a lot of marketing towards young people and whereas in the younger age groups parents have more control of what their children drink. I think that contributes. The whole series of pieces that contribute to children drinking more sugary drinks. Does that answer your question . Yes. So, taking a look at soda expenditures it tracks pretty closely to what we see with over weight and diabetes. Its more with people of color and the diabetes rate you see that same pattern emerging. It speaks to the fact that we have Significant Health inequities and Desperate Health outcomes. Lastly, a couple of points of impacts on sugary drinks. There is a recommendation can i go back to the diabetes hospitalization map. Roberto vargas pointed out area code 94124 on the bottom side