Concrete images of the sugar content in sugar-sweetened beverages reduces attraction to and selection of these beverages

Effects of immediate and distant health consequences: different types of health warning messages on sweets affect the purchase probability

BACKGROUND

Several health control policies have been discussed as a regulatory approach to tackle the increasing prevalence of obesity and other health risks related to sugar consumption. Health warnings, like the ones used in tobacco control worldwide, are one of the most promising approaches. However, in the case of health warning messages for food products, it is much more complicated and involves much more consumer involvement than tobacco guidance. Therefore, it is important to better understand the efficacy, evaluation, and reactance of health warning labels in the food sector regarding consumers' behavior, persuasion, and perceptions. The aim of this study was to examine how different types (design and message) of health warning messages in combination with graphical applications affect consumer behavior.

METHODS

In a 3 × 3 × 3 symmetrical design, 1,040 German participants completed an online discrete choice experiment including various text-only and image-and-text health warning labels on sweets. An accompanying questionnaire assessed socio-demographic variables as well as psychometric scales to understand the relationship between fear, control, reactance, and shocking/inhibiting/mediating health-related warnings.

RESULTS

Our results suggest that especially emotional graphical images combined with text health warning labels might be more influential. The health effects of immediate (caries) and more distant health consequences (diabetes/obesity) differ in their impact. Further, results show that especially when consumers engage in a danger control process for overweight, warning messages have a negative impact on their choices.

CONCLUSION

Hence, warning labels on sweets can potentially be a decisive factor when communicating health threats related to excessive sugar consumption. In the context of a targeted health policy, we see the need for further research, especially concerning the perception and understanding of noncommunicable diseases (NCDs) in the population.

Warning labels on alcoholic beverage containers: a pilot randomized experiment among young adults in Mexico

BACKGROUND

Little is known about the potential impacts of visible and up-to-date health warning labels on alcoholic beverage containers on a range of outcomes in low- and middle-income countries. We conducted an experimental study to test the potential impacts of visible health warning labels (on the principal panel of the package) on thinking about health risks, product attractiveness, visual avoidance, and intention to change alcohol use among students in Mexico aged 18-30 years.

METHODS

A double-blind, parallel-group, online randomized trial was conducted from November 2021 to January 2022 in 11 states in Mexico. In the control group, participants were presented with the image of a conventional beer can with a fictional design and brand. In the intervention groups, the participants observed pictograms with a red font and white backgrounds (health warning label in red-HWL red) or with a black font and yellow backgrounds (health warning label in yellow-HWL yellow), located at the top, covering around one-third of the beer can. We used Poisson regression models -unadjusted and adjusted for covariates- to assess differences in the outcomes across study groups.

RESULTS

Using intention-to-treat analysis (n = 610), we found more participants in groups HWL red and HWL yellow thought about the health risks from drinking beer compared to the control group [Prevalence Ratio (PR) = 1.43, CI95%:1.05,1.93 for HWL red; PR = 1.25, CI95%: 0.91, 1.71 for HWL yellow]. A lower percentage of young adults in the interventions vs control group considered the product attractive (PR 0.74, 95%CI 0.51, 1.06 for HWL red; PR 0.56, 95%CI 0.38, 0.83 for HWL yellow). Although not statistically significant, a lower percentage of participants in the intervention groups considered buying or consuming the product than the control group. Results were similar when models were adjusted for covariates.

CONCLUSIONS

Visible health warning labels could lead individuals to think about the health risks of alcohol, reducing the attractiveness of the product and decreasing the intention to purchase and consume alcohol. Further studies will be required to determine which pictograms or images and legends are most contextually relevant for the country.

TRIAL REGISTRATION

The protocol of this study was retrospectively registered on 03/01/2023: ISRCTN10494244.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial

INTRODUCTION

Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.

STUDY DESIGN

The study was an RCT.

SETTING/PARTICIPANTS

An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020.

INTERVENTION

Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).

MAIN OUTCOME MEASURES

Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies.

RESULTS

Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings.

CONCLUSIONS

SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03648138.

SnackTrack-An App-Based Tool to Assess the Influence of Digital and Physical Environments on Snack Choice

As food choices are usually processed subconsciously, both situational and food environment cues influence choice. This study developed and tested a mobile app to investigate the association between physical and digital environments on snack choices. SnackTrack was designed and used to collect data on the snack choices of 188 users in real-life settings during an 8-week feasibility trial. The app asks users to take a photo of the food they are planning to consume and to provide additional information regarding the physical environment and context in which this food was eaten. The app also displayed various user interface designs (i.e., different background images) to investigate the potential effects of images on snack choice. Preliminary results suggest that the time of snack obtainment did not have a significant effect on the healthfulness of the snacks chosen. Conversely, it was found that unhealthy background images appeared to encourage healthier snack choices. In conclusion, despite consumers having the knowledge to make healthy choices, environmental cues can alter food choices. SnackTrack, a novel tool to investigate the influence of physical and digital environments on consumers' food choices, provides possibilities for exploring what encourages (un)healthy eating behaviours.

"You can't just eat 16 teaspoons of sugar so why would you drink 16 teaspoons' worth of sugar?": a qualitative study of young adults' reactions to sugary drink warning labels

Background

Several jurisdictions have introduced nutrient warning front of pack (FoP) labels in an effort to curb consumption of ultra-processed foods and beverages high in free sugars (sugars added to foods and beverages, and sugars naturally present in honey, syrups, fruit juices and fruit juice concentrates). This study aimed to explore consumer understanding and perceptions of FoP warning labels that convey different nutritional and health information messages regarding the consumption of sugary drinks.

Methods

Sixteen focus groups were held with 4–8 young adults per group (aged 18–24; n = 105 participants in total) stratified by education level, location (rural centres, large cities) and gender (males, females) to ensure diversity. Labels shown to participants during group discussions included text warning labels of health effects, exercise equivalents, calorie/kilojoule information and sugar content as a “high in” label and as teaspoons (text and pictograms). Thematic analysis was undertaken.

Results

Four themes were identified related to participants’ perceived effectiveness of labels: the extent to which labels were perceived to be useful, relevant and credible; the extent to which a label elicited shock or disgust (perceived aversiveness); the extent to which the label message was resistant to self-exemption; and participants’ perceived potential of the label to reduce purchasing and consumption behaviour. Across all four themes, labels communicating the number of teaspoons of sugar in a sugary drink (whether by text or pictogram) were perceived as the most impactful, resistant to self-exemption and to have the greatest potential to reduce consumption, with enhanced reactions to the pictogram label. Labels depicting health effects, exercise equivalents, calorie/kilojoule information or a general ‘high in sugar’ warning were perceived by consumers to be less effective in one or more themes.

Conclusions

Labels conveying the amount of sugar in a beverage in teaspoons were perceived as highly factual, relatable and interpretable, and as having the greatest potential to impact consumption attitudes and intentions. Further quantitative studies are required to compare the potential effectiveness of the teaspoons of sugar labels in reducing purchasing and consumption behaviour than other alternative warning labels, such as health effects or “high in” sugar labels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13648-1.

Visual Juxtapositions as Exemplars in Messages Promoting Healthy Dietary Behavior

While health communicators often study strategic health messages, investigations of how visual message elements complement or inhibit persuasive efforts are sparse in the literature. Visual juxtapositions, which refer to one visual presentation featuring two images placed next to each other, are one such visual element. In the context of improving public communication efforts related to promoting healthy dietary choices, we use visual persuasion theory and exemplification theory to test whether different visual juxtapositions influence message recipients' expectations to share message content and reduce their consumption of unhealthy products (i.e., sugary drinks and salty foods). We carried out two studies, each a two-wave, longitudinal randomized experiment, to test for direct effects and assess the potential for indirect or delayed associations of visual persuasion appeals using visual juxtapositions. We consistently observed that a similarity visual juxtaposition evoked higher levels of surprise and expectations to share message content than a comparison juxtaposition or control condition immediately following message exposure; however, visual juxtapositions had no direct effects on unhealthy consumption expectations immediately following exposure or one-week following exposure. Levels of surprise were associated with both intended outcomes in the short-term (increased message sharing expectations) and unintended outcomes in the longer-term (increased consumption expectations). Overall, the study offers insights into the effects and associations of visual juxtapositions on message processing and persuasion outcomes, as well as raises questions about how to apply visual persuasion concepts and improve theorizing related to visual persuasion in health communication contexts.

Approach avoidance training to curb consumption of sugar-sweetened beverages - A pilot randomized controlled trial in healthy volunteers

Elevated consumption of sugar-sweetened beverages (SSBs) contributes to overweight and obesity. Automatic action tendencies like an approach bias might promote the consumption of SSBs. We investigated whether an Approach-Avoidance Training (AAT) reduces this approach bias and related behaviors like craving for and consumption of SSBs. Fifty-six healthy participants, with a self-reported SSB consumption of at least 330 ml per day, were randomized to 6 sessions of real or sham AAT. In the real AAT condition, participants were trained to react with avoidance movements to pictures of SSBs in an implicit learning paradigm (i.e. participants were instructed to respond to a task-irrelevant feature), whereas in the sham AAT condition the same pictures were used but no systematic (avoidance) reaction was trained. Approach bias, craving for SSB and SSB intake in a bogus taste test were assessed. Real AAT was not superior to sham AAT in any outcome measure. AAT in its current form and as a stand-alone intervention does not appear to be effective in reducing SSB consumption.

Signs of Warning: Do Health Warning Messages on Sweets Affect the Neural Prefrontal Cortex Activity?

In the global attempt to combat rising obesity rates, the introduction of health warning messages on food products is discussed as one possible approach. However, the perception of graphical health warning messages in the food context and the possible impact that they may have, in particular at the neuronal level, have hardly been studied. Therefore, the aim of this explorative study was to examine consumers’ reactions (measured as neuronal activity and subjective reporting) of two different types of graphical health warning messages on sweets compared to sweets without warning messages. One type used the red road traffic stop sign as graphical information (“Stop”), while the other one used shocking pictures (“Shock”), an approach similar to the images on cigarette packages. The neural response of 78 participants was examined with the neuroimaging technique functional near-infrared spectroscopy (fNIRS). Different hemodynamic responses in the orbitofrontal cortex (OFC), the frontopolar cortex (FOC), and the dorsolateral prefrontal cortex (dlPFC) were observed, regions which are associated with reward evaluation, social behavior consequences, and self-control. Further, the health warning messages were actively and emotionally remembered by the participants. These findings point to an interesting health information strategy, which should be explored and discussed further.

Impact of health warning labels on snack selection: An online experimental study

Excessive consumption of energy-dense food increases the risk of obesity, which in turn increases the risk of non-communicable diseases, including heart disease, type 2 diabetes and most non-smoking-related cancers. Health warning labels (HWLs) that communicate the adverse health consequences of excess energy consumption could reduce intake of energy-dense foods. The aim of the current study was to estimate the impact on selection of energy-dense snacks of (a) image-and-text HWLs (b) text-only HWLs and (c) calorie information. In a between-subjects, 3 (HWL: image-and-text, text-only, no label) x 2 (calorie information: present, absent), factorial experimental design, participants (N = 4134) were randomised to view a selection of energy-dense and non-energy-dense snacks with one of five label types or no label. The primary outcome was the proportion of participants selecting an energy-dense snack in a hypothetical vending machine task. The proportion of participants selecting an energy-dense snack was reduced in all label groups, relative to the no label group (no label: 59%; calories only: 54%; text-only HWL: 48%; text-only HWL with calories: 44%; image-and-text HWL: 37%; image-and-text HWL with calories: 38%). Compared to the no label group, participants were least likely to select an energy-dense snack in the image-and-text HWL group (OR = 0.46, 95%CI = 0.40, 0.54, p < 0.001). Health warning labels - particularly those including an image and text - have the potential to reduce selection of energy-dense snacks in an online setting. Their impact on selection and consumption in real-world settings awaits testing.

The effect of front-of-package labels or point-of-sale signage on consumer knowledge, attitudes and behavior regarding sugar-sweetened beverages: a systematic review

Context

Globally, the use of labels or signage targeting SSBs remains in its infancy and there is limited evidence available regarding its ability to decrease purchase and consumption of SSBs.

Objective

This systematic review aimed to synthesize the evidence on the effect of sugar- or health-related sugar-sweetened beverage (SSB) warning labels or signage on knowledge, attitudes, and beliefs, and SSB purchase and consumption.

Data sources

Nine databases – Ovid Medline, Emerald Insight, Scopus, Informit, Business Source Complete, CINAHL, Global Health, PsychINFO, and SocIndex – were searched along with grey literature from inception to December 2019. The PRISMA guidelines were applied for reporting this systematic review.

Study Selection

Studies examining the impact of front of pack (FOP) labels and/or point of sale (POS) signage highlighting added sugar content or its health risks were included.

Data extraction

Two authors independently extracted data on items, including study details, study design, population characteristics, intervention label details (type, duration, and settings), and outcomes measures. The Effective Public Health Practice Project tool was used to assess the study quality.

Data analysis

Findings were synthesized narratively.

Results

Twenty-one studies published between 1992 and 2019 were included. Of these, 16 studies examined the impact of FOP labels and 5 studies examined the impact of POS signage. Both FOP labels and POS signage were associated with improved health knowledge, attitudes, and beliefs regarding SSBs and reduced SSB purchases. Warning labels with diet-related health consequences were found to be particularly effective. Overall quality of studies was assessed as mixed.

Conclusion

Health- or sugar-related FOP labels and POS signage for SSBs are promising public health measures and may improve consumers’ health behaviors toward reduced SSB purchase and consumption.

An In-Depth Exploration of Knowledge and Beliefs Associated with Soda and Diet Soda Consumption

The need to reduce sugar-sweetened beverage (SSB) consumption is widely accepted, but whether artificially sweetened beverages (ASBs) are a recommended alternative is a growing policy issue because of emerging evidence of potential health effects associated with excess consumption. This study aimed to establish the extent of the Australian population's knowledge of the risks associated with consuming SSBs (e.g., soda) and ASBs (e.g., diet soda), which is essential for identifying which facets of knowledge to target with public health interventions. A national computer-assisted telephone survey of 3430 Australian adults was conducted in 2017. The survey included a range of measures to test associations between SSB and ASB knowledge and beliefs, demographic characteristics, and soda and diet soda consumption. Participants had an overall awareness that there were health risks associated with SSB and ASB consumption, but they lacked more detailed knowledge of health effects and nutritional composition of these drinks. These knowledge gaps are concerning given that SSBs and ASBs are consumed in large quantities in Australia. Public health interventions targeting consumers' limited knowledge and perceptions of health risks associated with excess sugar, calorie intake and artificial sweeteners are essential in reducing the health burden of obesity.

Evaluating and communicating about the healthiness of foods: Predictors of parents' judgments and parent-child conversations

Parents are typically in charge of purchasing the food that their children eat, but little is known about how parents decide if particular foods are healthy for their children and how their beliefs about nutrition influence their children's beliefs. In two studies, we investigated how parents of children ages 4 to 12 (N = 826) make decisions about the healthiness of foods, when presented with different representations of the same nutritional information. Providing parents with nutritional information did not influence their ratings of how healthy food items are, compared to when they are shown only pictures of the foods. Parents reported talking with their children about nutrition, believed they are the best source of information for children about nutrition, and believed their nutrition beliefs influence their child's beliefs. Our findings highlight the role of prior knowledge in food cognition and how beliefs about foods are transmitted from parents to children.

The impact of 'on-pack' pictorial health warning labels and calorie information labels on drink choice: A laboratory experiment

Sugar-sweetened beverages (SSBs) are one of the largest added sugar sources to diets in the UK and USA. Health warning labels reduce hypothetical selection of SSBs in online studies but uncertainty surrounds their impact on selection of drinks for consumption. Calorie information labels are also promising but their impact on SSB selection is unclear. This laboratory study assessed the impact on SSB selection of ‘on-pack’ labels placed directly on physical products: i.a pictorial health warning label depicting an adverse health consequence of excess sugar consumption; and ii.calorie information labels. Potential moderation of any effects by socio-economic position (SEP) was also examined. Participants - 401 adults, resident in England, approximately half of whom were of lower SEP and half of higher SEP, were asked to select a drink from a range of two non-SSBs and four SSBs (subsequent to completing a separate study assessing the effects of food availability on snack selection). The drinks included ‘on-pack’ labels according to randomisation: Group 1: pictorial health warning label on SSBs; Group 2: calorie information label on all drinks; Group 3: no additional label. The primary outcome was the proportion of participants selecting an SSB. Compared to not having additional labels (39%), neither the pictorial health warning label (40%) nor calorie information labels (43%) affected the proportion of participants selecting an SSB. Lower SEP participants (45%) were more likely to select an SSB compared to those of higher SEP (35%), but SEP did not moderate the impact of labels on drink selection. In conclusion, pictorial health warning labels may be less effective in reducing SSB selection in lab-based compared with online settings, or depending on label design and placement. Findings suggest that effects might be absent when choosing from real products with actual ‘on-pack’ labels, positioned in a ‘realistic’ manner. Field studies are needed to further assess the impact of ‘on-pack’ SSB warning labels in real-world settings to rule out the possible contribution of study design factors.

Effects of interventions based on the theory of planned behavior on sugar-sweetened beverage consumption intentions and behavior

There is increasing concern about the health risks of added dietary sugar, perhaps particularly when consumed in beverages that contain no essential nutrients (e.g., sodas). The purpose of this experiment was to examine the relative and combined efficacy of three interventions based on the theory of planned behavior (TPB) for motivating reductions in sugar sweetened beverage (SSB) consumption. Four-hundred-thirty undergraduates were randomised in a 2*2*2 factorial design. Participants received either information designed to increase awareness of the risks of SSB consumption or control information, and received either information about SSB consumption norms or no norms information, and either made plans to reduce their SSB consumption or engaged in a control planning task. Results demonstrated that the interventions, separately and in conjunction, resulted in greater intentions to reduce SSB consumption in the future, and there was evidence that these effects were mediated by the effects the interventions had on the TPB constructs. Further, the risks information resulted in more behaviors indicative of preparations to alter SSB consumption and those who engaged in the SSB planning task reported significantly lower SSB consumption at follow-up compared to controls. The three interventions utilized showed promise for altering SSB consumption intentions and behavior and, given their brevity and low cost, have potential to be developed into large scale community-based interventions that may lead to meaningful public health benefits.

Quantifying Actual and Perceived Inaccuracy When Estimating the Sugar, Energy Content and Portion Size of Foods

In order to adhere to dietary guidelines and manage health risks, consumers need to be able to estimate with some accuracy the sugar and energy content of foods. The present study compared how well participants could estimate the sugar and energy content of foods, the weight of foods, and approximate portion size (using a hand measure estimation aid). The study had three aims. First, it aimed to investigate differences in accuracy across the four measures. Second, it aimed to examine whether these differences in accuracy between estimation measures were accurately perceived by the participants. Third, it aimed to test if estimation accuracy was related to food journaling experience, body-mass index or gender. One hundred and ninety-seven participants took part in an estimation task and filled in a questionnaire. While the participants were inaccurate when using all four estimation measures, inaccuracy was most pronounced for sugar content (ds ≥ 0.39), which was consistently overestimated by between 62.1% and 98.5% of the sample. None of the other measures showed a consistent pattern of under- or overestimation. Participants’ perceived accuracy did not match their actual accuracy (rs ≤ |0.20|, ps ≥ 0.005). Actual accuracy showed only marginal covariation with food journaling experience (ts ≤ 2.01, ps ≥ 0.049, ds ≤ 0.14), body-mass index (rs ≤ |0.15|, ps ≥ 0.041) or gender (ts ≤ 3.17, ps ≥ 0.002, ds ≤ 0.46). It is particularly challenging for consumers to estimate the sugar content of food, which might have negative consequences for health and well-being. Thus, more education about sugar content and misperceptions is needed to support consumers so that they can make healthy food choices.

Impact of warning labels on sugar-sweetened beverages on parental selection: An online experimental study

Sugar-sweetened beverages (SSBs) are one of the largest added sugar sources to diets in the UK and USA, particularly among young people. Warning labels, including calorie information labels, could reduce SSB consumption but uncertainty surrounds the labels that are most effective. This study assessed the impact of labels containing (a) each of two image-based warnings and (b) calorie information, singly and together, on SSB selection by parents of 11-16-year-olds living in the UK. Using a 3 (disease image, sugar content image, no image) × 2 (calorie information, no calorie information) between-subjects experimental design, 2002 participants were randomised to see beverages with one of six labels and selected one for their child to consume. The primary outcome was the proportion of participants selecting an SSB. Data were collected in December 2017. Logistic regressions showed SSB selection was lower when labels contained an image-based warning (35%), compared to not having any label (49%) or just calorie information (43.5%). The disease image lowered selection more than the sugar image (32% vs 40.5%). Providing calorie information with the disease image had no additional impact on selection (33%) but enhanced the impact of the sugar image (36%). Image-based warning labels discourage SSB selection by parents for their children. Images depicting health consequences of excess sugar consumption have larger effects than those depicting sugar content. Calorie information does not add to the effect of the former but does to that of the latter. Field studies are needed to assess the impact of SSB warning labels in real-life settings.

Impact of Knowledge of Health Conditions on Sugar-Sweetened Beverage Intake Varies Among US Adults

PURPOSE

This study examined associations between knowledge of sugar-sweetened beverage (SSB)-related health conditions and SSB intake among US adults.

DESIGN

Quantitative, cross-sectional study.

SUBJECT

The 2014 SummerStyles survey data for 4163 US adults (≥18 years) were used.

MEASURES

The outcome measure was frequency of SSB intake (regular soda, fruit drinks, sports or energy drinks, sweetened coffee/tea drinks). Exposure measures were knowledge of 6 SSB-related health conditions: weight gain, diabetes, cavities, high cholesterol, heart disease, and hypertension.

ANALYSIS

Six logistic regression models were used to estimate adjusted odds ratios (ORs) for consuming SSBs ≥2 times/d according to knowledge of SSB-related health conditions.

RESULTS

Overall, 37.8% of adults reported consuming SSBs ≥2 times/d. Although most adults identified that weight gain (80.2%), diabetes (73.6%), and cavities (71.8%) are related to drinking SSBs, fewer adults identified high cholesterol (24.1%), heart disease (31.5%), and hypertension (33.0%) as being related to drinking SSBs. Crude analyses indicated that lower SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, diabetes, cavities, and heart disease. However, after adjustment for covariates, only lack of knowledge of the association between heart disease and SSBs was significantly associated with consuming SSBs ≥2 times/d (OR = 1.29) than non-SSB consumers.

CONCLUSIONS

The finding that knowledge of SSB-related health conditions, in general, was not associated with high SSB intake suggests that knowledge on SSB-related health conditions alone may not be sufficient for adult behavior change.

Knowledge of Health Conditions Associated With Sugar-Sweetened Beverage Intake Is Low Among US Hispanic Adults

PURPOSE

To examine associations between knowledge of health conditions and sugar-sweetened beverage (SSB) intake among Hispanic adults.

DESIGN

Quantitative, cross-sectional study.

SETTING

The 2015 Estilos survey data.

PARTICIPANTS

One thousand US Hispanic adults (≥18 years).

MEASURES

The outcome variable was frequency of SSB intake (regular soda, fruit drink, sports/energy drink, and sweetened coffee/tea drink). Exposure variables were knowledge of 6 SSB-related health conditions (weight gain, diabetes, dental caries, high cholesterol, heart disease, and hypertension).

ANALYSIS

Six multinomial logistic regression models were used to estimate adjusted odds ratios for consuming SSBs ≥3 times/day (high intake), in relation to knowledge of SSB-related health conditions.

RESULTS

Overall, 58% of Hispanic adults consumed SSBs ≥2 times/day and 36% consumed SSBs ≥3 times/day. Although most identified that weight gain (75%) and diabetes (76%) were related to drinking SSBs, only half identified this relation with dental caries (57%) and hypertension (41%). Even fewer identified high cholesterol (32%) and heart disease (32%) as related. In crude analyses, SSB intake was significantly associated with knowledge of the associations between SSBs and weight gain, dental caries, and heart disease; however, after adjusting for sociodemographics and acculturation, associations were no longer significant.

CONCLUSIONS

Although SSB intake was very high, knowledge of SSB-related health conditions was low and was not related to high SSB intake among US Hispanic adults. Education efforts alone may not be adequate for Hispanic adults to change their behaviors.

Pictorial instrument of food and nutrition education for promoting healthy eating

ABSTRACT To trace the course of building a pictorial instrument that explores semiotic resources about food and nutrition education. The instrument is directed at the treatment and prevention of obesity, considering the food and nutrition problems of the Brazilian population. The criteria for photo production were: images that could cause visual impact and transmit applied nutrition information, insinuating positive and negative eating practices for promoting healthy eating, and preventing and treating obesity. Themes were created to guide photo production, and preparations, food composition tables, and food labels were used for composing the images. Focus groups were conducted with nonobese and obese women, and dietitians to evaluate image comprehension. The pictorial instrument totaled to 20 photos, with 5 photos in each of the following themes: 'Sweet life, being aware of sugar', about sugar content in sweets and drinks; 'Tasty food with little fat', about fat content in foods; 'Eating well by making the best choices', about food replacements; and 'I take care of myself by eating healthy food, about encouraging fruit and vegetable intakes. The photos contain food, meals, and semiotic resources. The pictorial instrument describes four relevant themes to approach food problems in the Brazilian population. It can easily be used for both preventing and treating obesity, and for promoting healthy eating.