Opportunities in programs and policies to address the underlying drivers of sugary drink and water consumption in the Washington DC metro area: a qualitative community-based system dynamics approach.

Background: Though the Dietary Guidelines for Americans recommend that individuals drink water instead of sugar-sweetened beverages (SSBs), this behavior is influenced and reinforced by a complex network of structures and systems.

Objective: The objectives of this study were to develop a shared understanding among multiple stakeholders about the structural and underlying, interconnected drivers of SSB and water consumption in the Washington D.C. metro area and to have them identify feasible and impactful policy levers.

Design: A community-based system dynamics approach was used during a 2-day group model building workshop where stakeholders engaged to develop a shared visual representation of the underlying, interconnected drivers of SSB and water intake and to identify what they thought were impactful and feasible policy levers.

Participants/setting: Stakeholders were purposively recruited from diverse sectors (early childhood education (n=6), nutrition assistance programs (n=2), food policy council and advocacy groups (n=4), city government officials including municipal water (n=4), and food and beverage retail (n=1)) to participate in a group model building workshop in July of 2022 in Washington, D.C.

Analysis: Using member checking and iterative feedback, the research team synthesized the outputs from the workshop into one causal loop diagram and ranked policy levers.

Results: Stakeholders visualized 7 subsystems that drive water and SSB consumption, then identified and ranked 5 policy levers by potential impact and ease of implementation, including 1) increase public health spending (high impact/hard to do); 2) invest in new and updated infrastructure for public water (high impact/hard to do); 3) implement coordinated public health campaigns to promote drinking safe, palatable water as an alternative to SSB (low impact/easy to do); 4) provision of tap water filters (low impact/easy to do); and 5) limits on SSB marketing (high impact/debated easy-or-hard to do).

Conclusions: This participatory approach allowed stakeholders to envision multiple places to intervene in the system simultaneously to both decrease SSB and increase water consumption in the specific context of their community.