Strategies to reduce sugar-sweetened beverage consumption and increase water access and intake among young children: perspectives from expert stakeholders

Knowing Is Not Doing: A Qualitative Study of Parental Views on Family Beverage Choice

OBJECTIVE

Sugary drink consumption is associated with adverse health outcomes in children, highlighting the need for scalable family interventions that address barriers to water consumption. To inform development of a scalable, health-care-system-based intervention targeting family beverage choice, a formative qualitative study was conducted using semi-structured interviews with parents whose children were identified as over-consuming sugar-sweetened beverages (SSB) and/or fruit juice (FJ). The first goal of these interviews was to understand, in a diverse real-world patient population, what parents viewed as the primary drivers of their family's beverage choices, and explore how these drivers might need to be addressed in order to make changes to beverage consumption. A second goal was to explore parental preferences for planned intervention components. An exploratory goal of the interviews was to examine whether knowledge, attitudes, and beliefs around family beverage choice differed across racial and ethnic groups in this sample.

DESIGN

Semi-structured phone interviews were conducted and interviews audio-recorded and transcribed.

PARTICIPANTS

39 parents/caregivers of children ages 1-8 who over-consumed sugary drinks as determined by screenings at pediatric visits.

PHENOMENON OF INTEREST

Parents were interviewed about family beverage choices and preferences to inform development of a multi-component intervention.

ANALYSIS

Thematic analysis was performed, including comparison of themes across racial/ethnic groups.

RESULTS

Parents expressed that sugary drinks were unhealthy and water was a better alternative. Most were familiar with the health consequences of excess sugar consumption. They identified many reasons why sugary drinks are chosen over water despite this knowledge. One common reason was concern about tap water safety. Few differences were noted across racial and ethnic groups in our sample. Parents were enthusiastic about a technology-based intervention to be delivered through their child's doctor's office.

CONCLUSIONS AND IMPLICATIONS

Knowledge is not enough to change behavior. Beverage interventions need to be easy to access, make water more appealing, and elevate beverage choice above the "white noise" of everyday life. Delivering an intervention in a clinical setting could provide an extra level of care, while technology would reduce the amount of live contact and decrease the burden for clinicians and parents.

Can a simple plan change a complex behavior? Implementation intentions in the context of water drinking

Underhydration has significant adverse physical and mental health effects, yet many people drink too little water. Implementation intentions have been found to effectively promote many health behaviors, but little is known about the processes underlying their effects in naturalistic settings, and whether they could improve water drinking. This mixed-methods study assessed the impact and potential underlying processes of using implementation intentions to increase self-reported water intake over a five-day follow-up. Ninety-five participants (Mage = 39, SD = 12) received an educational quiz to increase their water drinking motivation before being randomly assigned to the control or intervention group. Participants also completed a qualitative survey that assessed the processes underlying their attempts to increase water intake. Quantitative results suggested that most participants increased their average daily water intake regardless of group. Qualitative results indicated that implementation intention participants struggled with remembering and the perceived effort of preparation and drinking behaviors, which reduced the effect of planning on behavior. This study provides essential theoretical and methodological considerations for researchers studying implementation intentions, as the effects and mechanisms of implementation intentions in real-life situations may be more complex than previously assumed. For example, the results suggest that implementation intentions did not automatize remembering and performing the behavior in ways the current literature theorizes. Other kinds of interventions may be needed to improve the complex daily-life behaviour of water drinking.

Alaska's Play Every Day Campaign Encourages Parents to Serve Healthy Drinks to Young Children

BACKGROUND

Sugary drink consumption by young children is a public health concern. The State of Alaska, partnering with the Alaska Native Tribal Health Consortium, implemented the Play Every Day social marketing campaign in 2019-2021 to encourage parents to serve healthy drinks to young children. The campaign's intended audience was parents who experience disproportionately poor nutrition outcomes: Alaska Native people, those living in rural communities, and those with low incomes and/or educational attainment. We described campaign development, implementation, and performance.

METHOD

Parents from the identified disproportionately affected populations participated in formative research. Campaign awareness and engagement questions were added to Alaska's child health surveillance system. Regression models assessed associations between campaign exposure and outcomes.

RESULTS

The sample included 476 Alaska mothers of 3-year-old children. Of the 34% who reported seeing the campaign, 21% said they changed drinks served to their child because of the campaign. Campaign awareness, engagement, and reported changes in drinks given to children because of the campaign were greater among Alaska Native mothers than White mothers. Among all mothers, those who said the campaign gave them new information or that they shared the campaign had 7 to 8 times greater odds for reporting changes in behavior than those not engaged with the campaign.

IMPLICATIONS FOR PRACTICE

Social marketing campaigns that encourage parents to serve healthy drinks to young children may change behavior. Resources should be systematically dedicated to research, implementation, and evaluation focused on specific populations. Partnering with trusted community-serving organizations likely improves outcomes in disproportionately affected populations.

Evaluation of Parental Acceptability and Use of Intervention Components to Reduce Pre-School Children's Intake of Sugar-Rich Food and Drinks

Knowledge is needed about effective tools that reach public health objectives focused on reducing the intake of sugar-rich foods and drinks. The purpose of this study was to assess the parental acceptability, use and motivational potential of intervention components developed in the randomized family-based trial ‘Are you too sweet?’ aimed at reducing the intake of sugar-rich foods and drinks among children (5–7 y). Intervention components included guidance on sugar-rich foods and drinks at a school health nurse consultation, a box with home-use materials and a digital platform. The methods used were a questionnaire among intervention families (n = 83) and semi-structured interviews with parents in selected intervention families (n = 24). Results showed the good acceptability and usefulness of the components, with reported frequencies of use of materials ranging from 48% to 94% and a high satisfaction rate with the school health nurse consultation. Personalized feedback and guidance from the school health nurse seemed to be a motivational trigger, and components that were compatible with existing practices were most frequently used. However, the components were not considered engaging by all families. Overall, intervention components were well received and hold the potential for enhancing parental knowledge and parenting practices regarding limiting the intake of sugar-rich foods and drinks.

How have media campaigns been used to promote and discourage healthy and unhealthy beverages in the United States? A systematic scoping review to inform future research to reduce sugary beverage health risks

Sugary beverage consumption is associated with many health risks. This study used a proof-of-concept media campaign typology to examine U.S. beverage campaigns that promoted healthy beverages and encouraged or discouraged sugary beverages. We used a three-step systematic scoping review to identify, organize, analyze, and synthesize evidence. Step 1 used Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines to search four electronic databases and gray literature through 2021. Step 2 categorized relevant media campaigns using a media campaign typology. Step 3 examined campaign evaluation outcomes. We identified 280 campaigns organized into six campaign typology categories. The media landscape was dominated by corporate marketing campaigns for branded sugary beverages (65.8%; n = 184) followed by public awareness (9.6%; n = 27), public policy (8.2%; n = 23), social marketing (7.1%; n = 20), corporate social responsibility (5.7%; n = 16), and countermarketing (3.6%; n = 10) campaigns. Evaluations for 20 unique campaigns implemented over 30 years (1992-2021) across 14 states showed reduced sugary beverage or juice and increased water or low-fat milk sales and intake. Positive short-term cognitive and mid-term retail and behavioral changes were reported. There was limited evidence for long-term policy, social norm, and population health outcomes. Future research is needed to use media campaigns in strategic communications to reduce sugary beverage health risks for Americans.

Restaurant kids' meal beverage offerings before and after implementation of healthy default beverage policy statewide in California compared with citywide in Wilmington, Delaware

OBJECTIVE

In 2019, California and Wilmington, Delaware' implemented policies requiring healthier default beverages with restaurant kids' meals. The current study assessed restaurant beverage offerings and manager perceptions.

DESIGN

Pre-post menu observations were conducted in California and Wilmington. Observations of cashiers/servers during orders were conducted pre-post implementation in California and post-implementation in Wilmington. Changes in California were compared using multilevel logistic regression and paired t tests. Post-implementation, managers were interviewed.

SETTING

Inside and drive-through ordering venues in a sample of quick-service restaurants in low-income California communities and all restaurants in Wilmington subject to the policy, the month before and 7-12 months after policy implementation.

PARTICIPANTS

Restaurant observations (California n 110; Wilmington n 14); managers (California n 75; Wilmington n 15).

RESULTS

Pre-implementation, the most common kids' meal beverages on California menus were unflavoured milk and water (78·8 %, 52·0 %); in Wilmington, juice, milk and sugar-sweetened beverages were most common (81·8 %, 66·7 % and 46·2 %). Post-implementation, menus including only policy-consistent beverages significantly increased in California (9·7 % to 66·1 %, P < 0·0001), but remained constant in Wilmington (30·8 %). During orders, cashiers/servers offering only policy-consistent beverages significantly decreased post-implementation in California (5·0 % to 1·0 %, P = 0·002). Few managers (California 29·3 %; Wilmington 0 %) reported policy knowledge, although most expressed support. Most managers wanted additional information for customers and staff.

CONCLUSIONS

While the proportion of menus offering only policy-consistent kids' meal default beverages increased in California, offerings did not change in Wilmington. In both jurisdictions, managers lacked policy knowledge, and few cashiers/servers offered only policy-consistent beverages. Additional efforts are needed to strengthen implementation of kids' meal beverage policies.

Sugar-sweetened beverages, effects on appetite and public health strategies to reduce the consumption among children: a review

Sugar-sweetened beverages (SSBs) consumption have been of public health concern and a target of interventions due to their high consumption and burden in health-related consequences, particularly in children and adolescents. SSBs provide high energy intake with low nutritional value and are a major contributor for added and free sugars intake of Portuguese in all age-groups, especially adolescents. Despite its recognized effect on weight gain, it might also disrupt appetite regulation. Research on the effect of SSBs on appetitive traits is still scarce and unclear, and the current knowledge of these potential effects will be discussed in this review. This review also aims to describe public health strategies implemented to decrease SSBs consumption among children, particularly in Portugal, such as: (i) implemented taxation measures and its impact in sales and in preventable cases of disease and death, (ii) marketing regulations applied to children and adolescents, and ultimately (iii) the intention of application of a single Front-of-Package labeling system in all countries, aiming to increase consumers’ food literacy.

Climate Change and State of the Science for Children's Health and Environmental Health Equity

INTRODUCTION

Climate change is impacting the physical and mental health of children and families. This is a state of the science update regarding the impacts of climate change for pediatric-focused health care providers and advanced practice registered nurses.

METHOD

Using an equity lens, the authors reviewed and synthesized current literature regarding the adverse impacts of climate change.

RESULTS

The poor and communities of color are disproportionately impacted by climate change. Physical health impacts include increased vector and water-born infectious diseases, increases in asthma and respiratory infections, and undernutrition. Social disruptions lead to human trafficking. Climate change is associated with mental health concerns, including anxiety and posttraumatic stress after natural disasters.

DISCUSSION

As clinicians, pediatric-focused providers, and advanced practice registered nurses should use multipronged and interdisciplinary approaches to address or prevent the adverse impacts of climate change. Advocacy at all government levels is necessary to safeguard children and vulnerable populations.

A Rationale for a Gamified E-Coach Application to Decrease the Consumption of Sugar Sweetened Beverages

The design and implementation of applications for behavior change should be preceded by careful analysis of the behavior change process and the target population. We, therefore, present on the basis of a blended research approach a rationale, opportunities and basic requirements for an application that offers a program for reducing intake of sugar sweetened beverages (SSB) by adolescents. This paper discusses the role of e-coaching and gamification as two high-touch design patterns in the behavior change process. Both design patterns aim at supporting the individual in a transformational journey from a current state toward a desired state where the detrimental behavior should be replaced by healthy alternative behavior. First, an elementary behavior scheme is introduced that frames three empirical studies. In the first study (plenary focus groups; n = 13), participants advised to include system recommendations for alternative healthy behavior, stressed the need for personalization of the e-coach and showed strong appreciation for the inclusion of gamification elements. The second study (online survey; n = 249) showed that SSB-intake is highly contextual and that reasons for (limiting) consumption SSB varies greatly between individuals, which the e-coach application should take into account. In a final small-scale pilot study (n = 27), we observed the potential of the inclusion of gamification elements, such as challenges and rewards, to increase compliance to the self-monitoring process of SSB consumption. Building upon these insights and prior studies, we argue that an e-coach mimics the collaborative practice of the program; its main task is to enrich the interaction with cooperative conversational experiences, in particular with respect to the alignment between user and system, motivational encouragement, personalized advice, and feedback about the activities. In addition, we outline that gamification not only has the potential to increase self-monitoring of the target behavior, user engagement, and commitment with the intervention program, but also enables a designer to shift long-term negative outcome of excessive intake in real life to short-term consequences in a virtual environment. In future larger follow-up studies, we advise to integrate the two design patterns within a social network of virtual and human agents that play a variety of competitive, normative and supportive roles.

Using a Community-Based Participatory Mixed Methods Research Approach to Develop, Evaluate, and Refine a Nutrition Intervention to Replace Sugary Drinks with Filtered Tap Water among Predominantly Central-American Immigrant Families with Infants and Toddlers: The Water Up @Home Pilot Evaluation Study

Descriptions of the implementation of community-based participatory mixed-methods research (CBPMMR) in all phases of the engagement approach are limited. This manuscript describes the explicit integration of mixed-methods in four stages of CBPR: (1) connecting and diagnosing, (2) prescribing-implementing, (3) evaluating, and (4) disseminating and refining an intervention that aimed to motivate Latino parents (predominantly Central American in the US) of infants and toddlers to replace sugary drinks with filtered tap water. CBPMMR allowed for co-learning that led to the identification of preliminary behavioral outcomes, insights into potential mechanisms of behavior change, and revisions to the intervention design, implementation and evaluation.

"I know it's just pouring it from the tap, but it's not easy": Motivational processes that underlie water drinking

Water drinking behaviour is under-researched despite the prevalence and adverse health consequences of underhydration. We conducted a qualitative exploration into the motivational processes underlying water drinking, informed by a grounded cognition perspective on desire and motivated behaviour. We interviewed and analysed data from 60 participants stratified by age, gender, and education level using thematic analysis, to generate three key themes. "Water as situated habits," suggests that participants form and maintain situated water drinking habits, so that within certain situations they regularly drink water. However, participants who situated their water intake only in one key situation (e.g., work routine), had low and inconsistent intake when they left this situation. Some situations happened so infrequently during the day (e.g., before bed) that participants' daily water intake was low. Many participants reported drinking water in reaction to thirst cues, but these were easily suppressed or ignored, so that water drinking was inconsistent. Participants who saw drinking water as part of their self-identity had consistent and high water intake across a variety of situations. "Knowledge and attitudes," suggests that few participants had knowledge or attitudes that promoted water intake (e.g., perceived water as positive or understood the importance of hydration). "Strategies underlying attempts to increase intake" suggests that many participants lacked insight into strategies to increase water intake, although they spontaneously discussed attempts to drink more. This lead to ineffective attempts at behaviour change. Participants' mentions of dehydration and their responses to a urine colour chart suggested that many participants were possibly underhydrated. Our findings suggest that interventions and practitioners attempting to increase water intake need to increase knowledge about the importance of hydration, and encourage individuals to develop effective situated water drinking habits.

Influence of dietary and activity patterns on weight status of Ukrainian school aged children

Objectives Dietary patterns and physical activity have significant influence on weight status. Despite numerous studies related to this topic, there is no existing research which provides complete population-based studies that identify the most significant predictors of pediatric obesity. Therefore, it has become the major goal of our study. Subjects and methods Three hundred school students between 10 and 17 years of age were participating in our study. All of them are currently attending various schools in city of Ternopil, Ukraine. Anthropometric measurements were performed for all participants. Information about food consumption and physical activity was obtained from distributed questionnaire. Logistic regression was used to identify the significant predictors of obesity. Results Lack of physical activity during week (OR=2.59 [95% CI 1.10-6.08]), long screen time in weekdays (OR=2.94 [95% CI 1.13-7.69]) and weekends (OR=3.63 [95% CI 1.55-8.50]), frequent consumption (OR=2.60 [95% CI 1.30-5.19]) and high amounts (OR=2.52 [95% CI 1.26-5.05]) of sweet beverages, fast-food consumption (OR=30.97 [95% CI 1.46-657.60]) and overeating (OR=3.99 [95% CI 1.26-5.05]) have increased chance to be overweight in children 10-17 years of age (p<0.05). Conclusion Decreased frequency in moderate physical activity per week, increased amount of sugar-sweetened beverages, fast-food consumption per day and food consumption without hunger, appear to be the most significant predictors of overweight and obesity among Ukrainian school-aged children.

Voluntary Kids' Meal Beverage Standards: Are They Sufficient to Ensure Healthier Restaurant Practices and Consumer Choices?

Many quick-service restaurants (QSRs) instituted voluntary kids’ meal default beverage standards (standards) between 2013 to 2017. Little is known about impacts of standards on QSR drive-through practices and on customer choices. This study assessed differences in restaurant practices including kids’ meal beverages shown on menu boards, offered by cashiers, and selected by customers in QSRs with and without voluntary standards. Observations (n = 111) and customer surveys (n = 84) were conducted in 2018 at QSRs with standards (n = 70) and without (n = 41) in low-income California, U.S. neighborhoods. Kids’ meal beverages on menu boards (n = 149) and offered by cashiers (n = 185) at QSRs with and without standards were analyzed using multilevel logistic regression. Significantly more menu boards at QSRs with standards (n = 103) vs. without (n = 46) featured only milk, water or unsweetened juice (65.1% vs. 4.4%; p < 0.001). Most cashiers at QSRs with standards and QSRs without (53.1%, 62.5%) asked what drink the data collector wanted rather than first offering default beverages. A small sample of customer interviews found that customers at QSRs with standards most commonly ordered juice (37.0%); at QSRs without standards, soda (45.5%). Although menu boards showed healthier kids’ meal beverages at QSRs with standards than without, cashier behavior was inconsistent. Results suggest additional measures (legislation, implementation support, enforcement) may be needed to ensure optimal implementation.

A systematic review of the effectiveness of promoting water intake to reduce sugar-sweetened beverage consumption

Objective

To examine whether the promotion of water intake could reduce sugar‐sweetened beverage (SSB) consumption or purchases independent of interventions that target SSBs.

Methods

Seven databases were systematically searched. Included studies used water promotion as the primary intervention; used a controlled trial, single group pre‐post, or prospective cohort study design; included a measure of SSB consumption or purchase; enrolled human participants of any age who lived in high‐income or middle‐income countries; contained original data; and appeared in a peer‐reviewed English‐language article published from 1 January 2000 to January 4, 2019. The search yielded 7068 publications, from which 108 were chosen for full‐text review. Seventeen were included in this review.

Results

Nine of the 17 studies were randomized controlled trials, six were nonrandomized controlled trials, and 2 were single‐group pre‐post studies. Participants were primarily children and adolescents. Interventions included water provision, education or promotion activities. Ten of 17 studies were at low or some/moderate risk of bias. Seven studies showed a statistically significant decrease in SSB consumption of which only 2 were at low or some/moderate risk of bias.

Conclusions

This review found limited evidence that interventions aimed solely at increasing water consumption reduce SSB intake. Further research is needed to investigate whether interventions that combine water promotion and SSB reduction strategies could be synergistic for reducing SSB intake.

Developing a national research agenda to reduce consumption of sugar-sweetened beverages and increase safe water access and consumption among 0- to 5-year-olds: a mixed methods approach

OBJECTIVE

Sugar-sweetened beverage (SSB) consumption in early childhood is a public health concern. Adequate hydration in early childhood is also important. We developed a national research agenda to improve beverage consumption patterns among 0-5-year-olds. This article focuses on the process used to develop this research agenda.

DESIGN

A mixed methods, multi-step process was used to develop the research agenda, including: (i) a scientific advisory committee; (ii) systematic reviews on strategies to reduce SSB consumption and increase water access and consumption; (iii) two stakeholder surveys to first identify and then rank strategies to reduce SSB consumption and increase water access and consumption; (iv) key informant interviews to better understand determinants of beverage consumption and strategies to improve beverage consumption patterns among high-risk groups; (v) an in-person convening with experts; and (vi) developing the final research agenda.

SETTING

This process included research and stakeholders from across the United States.

PARTICIPANTS

A total of 276 participants completed survey 1 and 182 participants completed survey 2. Key informant interviews were conducted with 12 stakeholders. Thirty experts attended the convening, representing academia, government, and non-profit sectors.

RESULTS

Thirteen key issue areas and 59 research questions were developed. Priority topics were beverage consumption recommendations, fruit-flavoured drink consumption, interventions tailored to high-risk groups, and family engagement in childcare.

CONCLUSIONS

This research agenda lays the groundwork for research efforts to improve beverage patterns of young children. The methods used can be a template to develop research agendas for other public health issues.