World trends in sugar-sweetened beverage and dietary sugar intakes in children and adolescents: a systematic review

Experiences and perspectives of sugar-sweetened beverage consumption among Indigenous adults living in Manitoba

Sugar-sweetened beverages (SSB) are a health policy target. Indigenous populations are among the highest consumers of SSB in Canada. However, the Truth and Reconciliation Commission calls on governments to recognize health disparities among Indigenous populations as a consequence of colonialism and governmental policies. The purpose of this analysis was to explore emergent perspectives of Indigenous adults on experiences and perspectives of SSB consumption. We conducted a community-based participatory study in partnership with three Indigenous-led organizations. From 2019 to 2022, we completed qualitative interviews with Indigenous adults living in Island Lake Anisininew First Nation, Flin Flon, and Winnipeg's North End, a neighbourhood with high concentration of Indigenous people. Interviews were audio-recorded, transcribed verbatim, and analyzed thematically. Seventy-four adults participated in interviews, including 46 women, 26 men, and two identifying as two-spirit. Many participants, across all three locations, repeatedly and consistently described SSB or sugar as an addiction, which formed the primary theme for this analysis: addictive-like consumption of SSB. Addictive-like SSB consumption included comparison to other addictive substances, loss of control, and physical symptoms resulting from SSB intake (both positive and adverse) or attempting to reduce SSB intake. We identified two other secondary themes, i) perceived drivers and contexts of SSB consumption, and ii) health outcomes as a motivator for change. Perceived drivers or contexts included consuming SSB as a means to cope with stress, boredom, and poverty; SSB intake as being intertwined with other addictions or addictive substances; and drinking alone. In conclusion, addictive-like SSB consumption was reported by Indigenous adults. To address SSB intake among Indigenous populations, trauma-informed approaches should be explored that consider the colonial context.

Evolution of household availability of added sugars and their sources in Brazil: analysis of Household Budget Surveys from 2002 to 2017

The objective of this study was to describe the evolution of household purchase of added sugars and their main food sources in Brazil. Nationally representative data from the Household Budget Surveys from 2002-2003, 2008-2009 and 2017-2018 were used. Energy and added sugar quantities were estimated by means of per capita food quantities. The items considered as food sources were: (1) table sugar: refined sugar and other energetic sweeteners and (2) processed and ultra-processed foods with added sugar: soft drinks; other drinks; sweets, candies and chocolates; cookies; cakes and pies and other foods. The parameters estimated were: mean share of added sugar in total energy and, for food sources, the share of added sugar in total sugar intake and the impact of variations in sources of added sugar between 2008 and 2017. There was a regular share of energy from added sugar to total energy intake between 2002 and 2008 but a reduced share in 2017. Between 2008 and 2017, there was a decrease in the share of refined sugar and other sweeteners and soft drinks to total sugar intake and an increased share of all other items. High-income households had a lower share of refined sugar and other energetic sweeteners, but a higher share of soft drinks, sweets, candies and chocolates. The decrease in added sugar in 2017 was mainly due to the lower share of soft drinks. In conclusion, Brazilians' total intake of added sugar was decreased, mostly owing to reduced consumption of sugar from soft drinks.

Sugar-sweetened beverage consumption and periodontitis among adults: A population-based cross-sectional study

AIM

Investigating the association between sugar-sweetened beverages (SSBs) and periodontitis and whether the awareness of diabetes modifies this relationship.

MATERIALS AND METHODS

Cross-sectional analysis was conducted using the National Health and Nutrition Examination Survey (NHANES III) data involving US adults aged 30-50. Periodontitis was classified according to the Centers for Disease Control and Prevention and American Academy of Periodontology (CDC-AAP), and SSB consumption as dichotomous (<5 or ≥5, <7 or ≥7 and <14 or ≥14 times/week), ordinal and continuous variables. Confounders included family income poverty ratio, education, race/ethnicity, sex, age, food energy intake, smoking and alcohol. Odds ratios (ORs) were obtained by logistic regressions using inverse probability weighting. Effect modification analysis was performed considering self-reported diabetes.

RESULTS

Among 4473 cases analysed, 198 self-reported diabetes. SSBs were associated with periodontitis when individuals consumed ≥5 (OR 1.64; 95% confidence interval [CI] = 1.30-2.06), ≥7 (OR 1.92; 95% CI = 1.50-2.46) and ≥14 (OR 2.19; 95% CI = 1.50-3.18) times/week. The combined effect of consuming SSBs (≥5 and ≥14 times/week) and self-reported diabetes had less impact than the cumulative effect.

CONCLUSIONS

SSB consumption was associated with higher odds of periodontitis, and the estimates were reduced among those with awareness of diabetes.

Trends in Sugar From Packaged Foods and Beverages Purchased by US Households Between 2002 and 2020

BACKGROUND

Excess sugar consumption is a public health concern in the United States. How sugar purchases have changed over time, whether there are disparities across subpopulations, and the contribution of various food groups are unclear.

OBJECTIVE

To assess trends in sugar from packaged foods and beverages purchased by US households between 2002 and 2020.

DESIGN

This is an open cohort study.

PARTICIPANTS/SETTING

We obtained data from the NielsenIQ U.S. Homescan Consumer Panel, which collects data on household purchases of all consumer packaged goods in 52 metropolitan and 24 non-metropolitan markets across the United States. We assessed data on food and beverage purchases for 1,163,447 household-years.

MAIN OUTCOME MEASURES

The primary outcomes are the total sugar in grams purchased per capita per day and percentage of calories from sugar, by sociodemographic group.

STATISTICAL ANALYSES PERFORMED

We used linear regression to estimate trends in total grams of sugar per capita per day, percentage of calories from sugar, and percentage of total sugar purchases by food or beverage group. We estimated means for select years and tested for significance compared with 2002 and with the previous timepoint and calculated the overall P-value for the linear trend using time series regression.

RESULTS

Total sugar purchases decreased over the study period, both in absolute terms (-37.2 g/capita/day; 95% confidence interval [CI], -38.7, -35.6) and as a percentage of total calories purchased (-5.3 percentage points; 95% CI, -5.5, -5.2). Sugar purchases declined for all sociodemographic groups, but disparities have persisted or widened, particularly among individuals who are non-Hispanic Black, low-income, and with lower educational attainment. Beverages' contributions to sugar purchases decreased 8.1 percentage points (95% CI, -8.4, -7.8).

CONCLUSION

In the United States, purchases of sugar declined, but disparities by socioeconomic status and race or ethnicity persisted or widened. Policies to further reduce sugar consumption and the burden of diet-related disparities are needed.

A scoping study on the social determinants of health and sugar consumption in the context of policy approaches for improving population health

OBJECTIVES

To conduct a scoping review of existing research on the social determinants of health, sugar consumption and public health policy responses to address or improve health outcomes.

METHODS

A total of 13 categories were developed to reflect the authors' interest in the overall focus on the social determinants of health, sugar as an independent risk factor, upstream policy action ('whole populations'), downstream policy action ('targeted') and two contemporary policy strategies (namely 'Vulnerable populations' and 'Proportionate Universalism'). The search strategy was then performed on MEDLINE (via Ovid) and Web of Science, and was limited to the English language. No time limits prior to when the database search was conducted in 2022 were set to explore the full extent of the literature in this field.

RESULTS

Five hundred and sixty articles were retrieved, of which 181 met the criteria for review. When all categories were applied, the findings showed that 76% of papers focusing on sugar consumption as a risk factor for non-communicable diseases (NCDs) mentioned the social determinants of health. The majority of studies (60%) recommended downstream interventions, with 40% recommending 'upstream' interventions. A limited proportion (12%) of research work was published in dental journals. Research had been done using predominantly quantitative methods (66% of articles), with 24% of studies adopting a mixed methods approach, and 8% being exclusively qualitative. Research on contemporary strategies for sugar reduction were focused on the 'Global North' and 98% of papers used individual level data focused on targeted approaches, highlighting that there is little direct evidence for contemporary strategies aimed at reducing sugar consumption.

CONCLUSIONS

Whilst the majority of public and dental health research argues that there is a need to address the social determinants of health, the findings from this study highlight that very few empirical studies have been designed to directly inform contemporary strategies for sugar reduction. More research is therefore needed that can directly assess the evidence for contemporary strategies in public health policy.

Sugar-Sweetened Beverage Consumption and Its Association With Dental Caries Among Adolescents in Erbil, Iraq: A Cross-Sectional Study

Background Sugar-sweetened beverages are one of the most common sources of added sugar in the diet and have been associated with an increased risk of dental caries, obesity, major chronic diseases, and possibly cancer. Dental caries is a diet-related, highly prevalent, and preventable oral disease. The objective of this study was to assess the frequency of sugar-sweetened beverage consumption and its association with dental caries in adolescents in Erbil, Iraq. Methods This is a cross-sectional study that invited 11- to 16-year-old intermediate school students (n=380) in Erbil, Iraq. Data collection comprised a validated questionnaire and a clinical examination. In addition, dietary data were collected by using two non-consecutive 24-hour recalls. The mean of the daily consumption of sugar-sweetened beverages over a two-day period was calculated. Dental caries was diagnosed based on World Health Organization (WHO) criteria and was reported as a decayed, missing, and filled permanent tooth (DMFT). A multiple regression model was used to assess the influence of sugar-sweetened beverages on dental caries experience (DMFT). SPSS version 26 (Armonk, NY: IBM Corp) was used to analyze the data at the 5% significance level. Results Of the 380 students interviewed, one participant was excluded because of incomplete data. The participant's mean age and standard deviation (SD) were 13.3±1.2. A total of 54.1% of the students were female. The mean daily intake of sugar-sweetened beverages was 686.71±197.50 mL per day. Male students consumed more beverages than female students (p<0.001). The most frequently consumed sugar-sweetened beverages were sweetened tea and coffee, and the least frequently consumed beverages were milk and dairy products. The mean decayed, missing, and filled permanent tooth (DMFT) was 94.58±2.73. Results of multiple regression analysis showed that caries experience (DMFT) was associated with insufficient toothbrushing (p<0.001), plaque-affected sextants (p=0.001), and male sex (p=0.016). The model also showed a significant association between sugar-sweetened beverage consumption and dental caries experience (DMFT) (regression coefficient=0.008, CI: 0.006-0.009, p<0.001). Conclusions Adolescents in Erbil, Iraq, consumed sugar-sweetened beverages on a frequent basis, and male students consumed more sugary beverages than females. The higher frequency of these beverage consumptions was associated with a higher dental caries experience. Consequently, reducing sugar-sweetened beverage consumption could have a significant positive public health impact.

Sustaining Healthy Habits: The Enduring Impact of Combined School-Family Interventions on Consuming Sugar-Sweetened Beverages among Pilot Chinese Schoolchildren

This study assesses the enduring impact of combined school- and family-based interventions on reducing the consumption of sugar-sweetened beverages (SSBs) among schoolchildren in China. Two primary schools were assigned at random to either the Intervention Group or the Control Group, in Nanjing, eastern China. All students were in grade three and received an invitation to participate. In the first year, students in the Intervention Group received one-year intervention measures, including monthly monitoring, aiming to decrease the consumption of SSBs. Students in the Control Group only received regular monitoring without interventions. In the second year, both groups received only regular monitoring, without active interventions. A generalized estimating equations model (GEE) was used to assess the intervention effects. After two years, relative to the Control Group, the Intervention Group had a significantly improved knowledge of SSBs and an improved family environment with parents. In the Intervention Group, 477 students (97.3%) had adequate knowledge about SSBs, compared to 302 students (83.2%) in the Control Group (X2 = 52.708, p < 0.001). Two years later, the number of students who stated 'my home always has SSBs' in the Intervention Group (7.8%) was fewer than that in the Control Group (12.4%), which was a statistically significant finding (p < 0.05). One year later, both the frequency and the quantity of SSB consumption in the Intervention Group were less than those in the Control Group; such differences between the groups remained statistically significant for the quantity but not for the frequency of SSB consumption two years later. In the Intervention Group, the frequency of SSB consumption was significantly reduced by 1.0 times per week, compared to a reduction of 0.1 times per week in the Control Group in the first year (p < 0.05). In the second year, the frequency of SSB consumption was reduced by 0.8 times per week in the Intervention Group, compared to 0.5 times per week in the Control Group (p > 0.05). In the first year, the volume of SSB consumption was significantly reduced by 233 mL per week in the Intervention Group, compared to an increase of 107 mL per week in the Control Group (p < 0.05). In the second year, the volume of SSB consumption was reduced by 122 mL per week in the Intervention Group compared to an increase of 31 mL per week in the Control Group (p > 0.05). The combined school-based and family-based interventions had a positive effect on the students' knowledge of SSBs and their family dynamics during the first and second year. Relative to the Control Group, the Intervention Group had a statistically significant reduction in SSB consumption after 1 year, but not after 2 years.

Trends in Calcium Intake among the US Population: Results from the NHANES (1999-2018)

Inadequate calcium intake is common in the US. Trends in calcium intake among the US population have been less studied, especially in more recent years. We used data from the National Health and Nutrition Examination Survey (NHANES) 1999-2000 to 2017-2018 to study trends in calcium derived from diet and dietary supplements among the US population aged 2 years, stratified by sex, age group, race, and ethnicity. Among the 80,880 participants included in our study, a substantial portion consistently lacked sufficient calcium intake, even when considering calcium from supplements. Concerning trends were observed over the more recent ten years (2009-2018), with decreased dietary calcium intake and no significant improvement in the prevalence of dietary calcium intake < Estimated Average Requirement (EAR) or the prevalence of taking calcium-containing dietary supplements among them. Decreasing trends in dietary calcium intake were more concerning among men, children, and non-Hispanic Whites. Attention should be given to subgroups with higher calcium intake requirements (e.g., 9-18 years and 60+ years), and subgroups with low levels of dietary calcium and a low prevalence of obtaining calcium from dietary supplements (e.g., the non-Hispanic Black subgroup). Concerning trends of calcium intake were observed among the US population from 2009 to 2018. Tailored guidance on dietary choices and dietary supplement use is required to change consumers' behaviors.

Competitive Foods' Nutritional Quality and Compliance with Smart Snacks Standards: An Analysis of a National Sample of U.S. Middle and High Schools

Snacks and beverages are often sold in addition to meals in U.S. schools ("competitive foods"), but their current nutritional quality and compliance with national Smart Snacks standards are unknown. This study assessed competitive foods in a national sample of 90 middle and high schools. Differences in compliance by school characteristics were measured using mixed methods analysis of variance. Overall, 80% of the schools in the sample sold competitive foods; but they were less commonly available in schools with universal free school meal (UFSM) policies. A total of 840 unique products were documented and, on average, 75% were compliant with Smart Snacks standards. A total of 56% aligned with recommended added sugar limits (<10% of calories); and 340 unique products (40%) aligned with both sugar and Smart Snacks standards. Approximately one-fifth of competitive foods contained synthetic dyes, and 31% of beverages contained artificial sweeteners. Smart Snacks standards compliance was greater when competitive foods were overseen by food service departments, in comparison with others (e.g., principals, student organizations, or outside vendors [77% vs. 59% compliance; p = 0.003]). Therefore, district wellness policies should consider requiring food service departments to oversee competitive foods. Federal and state policies should limit added sugars, artificial sweeteners, and synthetic dyes. This appears to be highly feasible, given the substantial number of products that meet these criteria. UFSM policies should also be considered to support healthier school meal environments more broadly.

Sugar-sweetened beverage intakes among adults between 1990 and 2018 in 185 countries

Sugar-sweetened beverages (SSBs) are associated with cardiometabolic diseases and social inequities. For most nations, recent estimates and trends of intake are not available; nor variation by education or urbanicity. We investigated SSB intakes among adults between 1990 and 2018 in 185 countries, stratified subnationally by age, sex, education, and rural/urban residence, using data from the Global Dietary Database. In 2018, mean global SSB intake was 2.7 (8 oz = 248 grams) servings/week (95% UI 2.5-2.9) (range: 0.7 (0.5-1.1) in South Asia to 7.8 (7.1-8.6) in Latin America/Caribbean). Intakes were higher in male vs. female, younger vs. older, more vs. less educated, and urban vs. rural adults. Variations by education and urbanicity were largest in Sub-Saharan Africa. Between 1990 and 2018, SSB intakes increased by +0.37 (+0.29, +0.47), with the largest increase in Sub-Saharan Africa. These findings inform intervention, surveillance, and policy actions worldwide, highlighting the growing problem of SSBs for public health in Sub-Saharan Africa.

Association between Hyperactivity and SSB Consumption in Schoolchildren: A Cross-Sectional Study in China

Sugar-sweetened beverages (SSBs) consumption has risen significantly, which may lead to various health problems. Studies about the association between SSBs and attention-deficit/hyperactivity disorder (ADHD) in children are rare and inconsistent. We have used the two-stage cluster sampling method to select 6541 students aged 6-12. We further investigated their basic information and SSB intake. Teachers' questionnaires and parents' questionnaires were used to evaluating the hyperactive behaviors in children. We examined the associations between SSB consumption and hyperactivity index (HI) by adopting the censored least absolute deviation (CLAD) estimator. Then, we further evaluated the impacts of sex and age on the association between SSB intake and hyperactivity. Children who weekly drank SSB two or more times were associated with 0.05 (0.04, 0.07) and 0.04 (0.02, 0.06) higher scores of ln (HI+1) reported by teachers and parents, respectively, compared to non-consumers children (p for trend < 0.05). A stronger association between SSB intake and hyperactivity occurred in girls and old children. (p for interaction < 0.05). SSB intake has a positive correlation with the risk of hyperactivity in children, and the frequency of SSB consumption and hyperactivity have a dose-response relationship.

Causal relationship of sugar-sweetened and sweet beverages with colorectal cancer: a Mendelian randomization study

BACKGROUND AND AIM

Prospective cohort studies have suggested that sugar-sweetened beverages (SSBs) intake is significantly associated with the risk of colorectal cancer (CRC). However, it remains unclear whether this observed association was susceptible to potential confounding factors due to the long-term development process of CRC, and the risk of CRC associated with sweet beverages has rarely been reported. We aimed to investigate the association between SSBs/sweet beverages and CRC risk.

METHODS

We performed two-sample Mendelian randomization (MR) analysis using independent genetic variants for SSBs and sweet beverages from a published genome-wide association study (GWAS). Summary statistics for instrument-outcome associations from two databases for malignant neoplasms of the colon and the rectum (FinnGen and UK Biobank). The inverse weighted method (IVW) meta-analysis was the main method used to estimate the relationship, and sensitivity analyses were performed with Cochran's Q test, leave-one-out analysis, MR-Egger regression, Steiger filtering, and the MR PRESSO test.

RESULTS

Genetically predicted SSBs intake was associated with a higher colonic malignant neoplasms risk (odds ratio (OR): 1.013; 95% confidence interval (CI) 1.001, 1.026; P = 0.036) in a combined sample size of 579,986 individuals (4029 cases). Such a significant causal effect of SSBs on rectal malignant neoplasms or sweet beverages on CRC was not observed.

CONCLUSION

Our findings corroborated a causal association between SSBs and colonic malignant neoplasms risk but did not support such a relationship in the analysis of the rectal malignant neoplasms nor the sweet beverage intake, which might be interpreted with caution and further confirmed.

Sugar-Sweetened Beverages and Metabolic Risk in Children and Adolescents with Obesity: A Narrative Review

Sugar-sweetened beverages (SSBs) are major contributors of free sugars to the diet. A strong relationship between SSB intake and weight gain is described.

METHODS

we performed a narrative review to present an overview of the role of SSBs as a pivotal contributor in the development of obesity and metabolism-related complications.

RESULTS

different factors influence SSB consumption in children, including economic variables, individual attributes and behaviors to environmental factors, parent features and parents' behaviors. Data suggest that SSB intake has a negative effect on weight and obesity-related diseases. The leading mechanism linking SSB intake to the risk of gaining weight is decreased satiety and incomplete compensatory reduction in energy intake at meals following ingestion of liquid calories. Additionally, the effects of SSBs on gut microbiota and on eating behaviors were also reported. An association between SSB intake, weight gain and cardiometabolic risks is evident. Consumption of SSBs had a significant impact on the prevalence of obesity and related metabolic risks, including insulin resistance, type 2 diabetes, hypertension and metabolic syndrome.

CONCLUSIONS

Limiting consumption of SSBs and increasing knowledge of the effect of SSBs on early metabolic and cardiovascular disorders will be useful in developing strategies to counteract the problem and to prevent obesity and related complications.Key future research areas for which further studies are needed include investigating the long-term effects of SSBs on health outcomes as well as analyzing the health effects of sugar consumed in solid compared to liquid forms and further elucidating the biological mechanisms of sugar addiction and energy compensation.

Applying the temporal self-regulation theory to understand sugar-sweetened beverage consumption among Chinese college students

Objective

Worldwide, there is a growing trend that college students are consuming more and more sugar-sweetened beverages (SSBs). In order to develop effective intervention strategies, it is important to explore what social-cognitive factors impact on college students' SSB consumption. Building on the temporal self-regulation theory (TST), the current study aimed to examine the effects of intention, behavioral prepotency, and self-regulatory capacity on SSB consumption among college students.

Design

Data were collected from five hundred Chinese college students online. Participants self-reported their intention, behavioral prepotency (environmental cues and habits), self-regulatory capacity, and behaviors of SSB consumption.

Results

Study findings showed that intention, behavioral prepotency, and self-regulatory capacity accounted for 32.9% of variance in SSB consumption. In terms of the direct effects, intention, behavioral prepotency, and self-regulatory capacity were significantly associated with the SSB consumption among college students. In addition, self-regulatory capacity and habits but not the environmental cues showed significant moderation effects on the intention-SSB consumption path, indicating that individual factors rather than environmental cues influenced the intention-behavior path of SSB consumption among college students.

Conclusion

Findings of the current study demonstrated that the TST can be used to explain and understand the impacts of social-cognitive factors on college students' SSB consumption. Future research can apply TST to develop effective intervention programs targeting the reduction of SSB consumption among college students.

Effects of nutritional intervention strategies in the primary prevention of overweight and obesity in school settings: systematic review and network meta-analysis

Objective

To examine the effects of different nutritional intervention strategies in the school setting on anthropometric and quality of diet outcomes by comparing and ranking outcomes in a network meta-analysis.

Design

Systematic review and network meta-analysis.

Data sources

PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Education Resources Information Centre (ERIC), PsycInfo, CAB Abstracts, Campbell Library, Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) BiblioMap, Australian Education Index, Joanna Briggs Institute Evidence-Based Practice (JBI EBP) database, Practice-based Evidence in Nutrition (PEN) database, ClinicalTrials.gov, Current Controlled Trials, and World Health Organization International Clinical Trials Registry Platform.

Eligibility criteria for selecting studies

A systematic literature search was performed from inception to 2 May 2022. Cluster randomised controlled trials meeting these study criteria were included: generally healthy school students aged 4-18 years; intervention with ≥1 nutritional components in a school setting; and studies that assessed anthropometric measures (eg, body mass index, body fat) or measures related to the quality of diet (eg, intake of fruit and vegetables), or both. Random effects pairwise meta-analyses and network meta-analyses were performed with a frequentist approach. P scores, a frequentist analogue to surface under the cumulative ranking curve, ranging from 0 to 1 (indicating worst and best ranked interventions, respectively) were calculated. Risk of bias was assessed with Cochrane's RoB 2 tool. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework was used to rate the certainty of evidence.

Results

51 cluster randomised controlled trials involving 75 954 participants and seven intervention nodes were included. Inconsistency could not be assessed (except for intake of fruit and vegetables) because the network meta-analyses were based mainly on star shaped networks with no direct evidence for specific pairs of nutritional interventions. Overall, little or no evidence was found to support a difference in body mass index, body weight, body fat, or waist circumference and moderate improvements in intake of fruit and vegetables with nutritional interventions in a school setting. Low to moderate certainty of evidence further suggested that multicomponent nutritional interventions likely reduced the prevalence (odds ratio 0.66, 95% confidence interval 0.55 to 0.80) and incidence (0.67, 0.47 to 0.96) of overweight compared with a control group. Based on low certainty of evidence, nutrition education and multicomponent interventions may be more effective than a control group (ie, usual practice) for increasing intake of fruit and vegetables. Multicomponent nutritional interventions were ranked the most effective for reducing body mass index (P score 0.76) and intake of fat (0.82). Nutrition education was ranked as best for body mass index z score (0.99), intake of fruit and vegetables (0.82), intake of fruit (0.92), and intake of vegetables (0.88).

Conclusions

The findings suggest that nutritional interventions in school settings may improve anthropometric and quality of diet measures, potentially contributing to the prevention of overweight and obesity in childhood and adolescence. The findings should be interpreted with caution because the certainty of evidence was often rated as low. The results of the network meta-analysis could be used by policy makers in developing and implementing effective, evidence based nutritional intervention strategies in the school setting.

Systematic review registration

PROSPERO CRD42020220451.

Parental food consumption and diet quality and its association with children's food consumption in families at high risk of type 2 diabetes: the Feel4Diabetes-study

OBJECTIVE

To examine the parental food consumption and diet quality and its associations with children's consumption in families at high risk for developing type 2 diabetes mellitus across Europe. Also, to compare food frequency consumption among parents and children from high-risk families to the European Dietary guidelines/recommendations.

DESIGN

Cross-sectional study using Feel4diabetes FFQ.

SETTING

Families completed FFQ and anthropometric measures were obtained. Linear regression analyses were applied to investigate the relations between parental food consumption and diet quality and their children's food consumption after consideration of potential confounders.

PARTICIPANTS

2095 European families (74·6 % mothers, 50·9 % girls). The participants included parent and one child, aged 6-8 years.

RESULTS

Parental food consumption was significantly associated with children's intake from the same food groups among boys and girls. Most parents and children showed under-consumption of healthy foods according to the European Dietary Guidelines. Parental diet quality was positively associated with children's intake of 'fruit' (boys: β = 0·233, P < 0·001; girls: β = 0·134, P < 0·05) and 'vegetables' (boys: β = 0·177, P < 0·01; girls: β = 0·234, P < 0·001) and inversely associated with their 'snacks' consumption (boys: β = -0·143, P < 0·05; girls: β = -0·186, P < 0·01).

CONCLUSION

The present study suggests an association between parental food consumption and diet quality and children's food intake. More in-depth studies and lifestyle interventions that include both parents and children are therefore recommended for future research.

Unhealthy Diets Induce Distinct and Regional Effects on Intestinal Inflammatory Signalling Pathways and Long-Lasting Metabolic Dysfunction in Rats

The intestinal epithelium is a principal site for environmental agents’ detection. Several inflammation- and stress-related signalling pathways have been identified as key players in these processes. However, it is still unclear how the chronic intake of inadequate nutrients triggers inflammatory signalling pathways in different intestinal regions. We aimed to evaluate the impact of unhealthy dietary patterns, starting at a younger age, and the association with metabolic dysfunction, intestinal inflammatory response, and obesity in adulthood. A rat model was used to evaluate the effects of the consumption of sugary beverages (HSD) and a Western diet (WD), composed of ultra-processed foods. Both diets showed a positive correlation with adiposity index, but a positive correlation was found between the HSD diet and the levels of blood glucose and triglycerides, whereas the WD diet correlated positively with triglyceride levels. Moreover, a distinct inflammatory response was associated with either the WD or HSD diets. The WD induced an increase in TLR2, TLR4, and nuclear factor-kappa B (NF-κB) intestinal gene expression, with higher levels in the colon and overexpression of the inducible nitric oxide synthase. In turn, the HSD diet induced activation of the TLR2-mediated NF-κB signalling pathway in the small intestine. Altogether, these findings support the concept that early intake of unhealthy foods and nutrients are a main exogenous signal for disturbances of intestinal immune mechanisms and in a region-specific manner, ultimately leading to obesity-related disorders in later life.

Are there plastic particles in my sugar? A pioneering study on the characterization of microplastics in commercial sugars and risk assessment

Although several studies are confirming the ubiquity of microplastics (MPs) in environments, our knowledge about their effects on human health is still very limited. Therefore, while we have not gathered definitive information on their consequences, studies that aim to identify the MPs sources constitute subsidies to better understand the various exposure pathways to these pollutants. Thus, we investigated the possible presence of MP-like particles in five brands of commercial sugars and two unpacked, unbranded, and unlabeled sugars (hereinafter referred to as "non-branded"), obtained from different supermarkets in Dhaka (Bangladesh). Surprisingly, MPs-like particles were identified in all analyzed samples and taken together, our data demonstrated similar variations (between branded and non-branded samples) in terms of number, size, shape, color, and polymer composition. The number of plastic particles/kg sugar was, on average, 343.7 ± 32.08 (mean ± SEM), having been observed a tendency for a higher frequency of MPs < 300 μm. Overall, microfibers and spherules were the most and the predominant colors of MPs (in general) were black, pink, blue, and brown. The FT-IR analysis confirmed the chemical nature of MPs (in branded and non-branded), having identified nine polymeric types (ABS, PCV, PET, EVA, CA, PTFE, HDPE, PC, and nylon), being ABS and PVC the most frequent. Furthermore, we estimate that sugar consumption in Dhaka City can cause the ingestion of millions of tons of MPs annually (2.4 to 25.6 tons) (with an average of 10.2 tons). Our study is the most comprehensive report on the MP's occurrence in sugar, confirming that the ingestion of this food constitutes an important route of human exposure to these micropollutants and, therefore, serves as a baseline for future assessments and useful for generating efficient strategies to control MPs.

Association between Body Mass Index with Sugar-Sweetened and Dairy Beverages Consumption in Children from the Mexico-USA Border

The consumption of sugar-sweetened beverages has been associated with the onset of cardiometabolic diseases. The aim of this study was to describe consumption patterns of sugar-sweetened and dairy beverages and to evaluate their correlation with the body mass index in children residing at the Mexico−USA border. A total of 722 (370 girls, 352 boys) elementary school children aged 9 to 12 years from Tijuana, Mexico, participated in the study. Anthropometric measures were recorded, and a beverage intake questionnaire was completed by the children’s parents. Significant age by sex interactions were found on body mass index Z-scores (p < 0.01). Boys showed higher sugar intake (p < 0.05) and total relative energy consumption from sugar (p < 0.05) than girls. The energy consumption from sugar-sweetened and dairy beverages was similar between sexes (p > 0.05). Sugar intake from beverages was higher than the limit recommended by the World Health Organization in boys (66%) and girls (44%). A high frequency of consumption of sugar-sweetened beverages and similar intake of dairy beverages were found in children from the Mexico−USA border. The high consumption of sugar exceeds international recommendations and should be carefully monitored.

"Sugar-Sweetened Beverages" Is an Independent Risk From Pancreatic Cancer: Based on Half a Million Asian Cohort Followed for 25 Years

Although the link between sugar-sweetened beverages (SSB) and pancreatic cancer has been suggested for its insulin-stimulating connection, most epidemiological studies showed inconclusive relationship. Whether the result was limited by sample size is explored. This prospective study followed 491,929 adults, consisting of 235,427 men and 256,502 women (mean age: 39.9, standard deviation: 13.2), from a health surveillance program and there were 523 pancreatic cancer deaths between 1994 and 2017. The individual identification numbers of the cohort were matched with the National Death file for mortality, and Cox models were used to assess the risk. The amount of SSB intake was recorded based on the average consumption in the month before interview by a structured questionnaire. We classified the amount of SSB intake into 4 categories: 0–<0.5 serving/day, ≥0.5–<1 serving per day, ≥1–<2 servings per day, and ≥2 servings per day. One serving was defined as equivalent to 12 oz and contained 35 g added sugar. We used the age and the variables at cohort enrolment as the reported risks of pancreatic cancers. The cohort was divided into 3 age groups, 20–39, 40–59, and ≥60. We found young people (age <40) had higher prevalence and frequency of sugar-sweetened beverages than the elderly. Those consuming 2 servings/day had a 50% increase in pancreatic cancer mortality (HR = 1.55, 95% CI: 1.08–2.24) for the total cohort, but a 3-fold increase (HR: 3.09, 95% CI: 1.44–6.62) for the young. The risk started at 1 serving every other day, with a dose–response relationship. The association of SSB intake of ≥2 servings/day with pancreatic cancer mortality among the total cohort remained significant after excluding those who smoke or have diabetes (HR: 2.12, 97% CI: 1.26–3.57), are obese (HR: 1.57, 95% CI: 1.08–2.30), have hypertension (HR: 1.90, 95% CI: 1.20–3.00), or excluding who died within 3 years after enrollment (HR: 1.67, 95% CI: 1.15–2.45). Risks remained in the sensitivity analyses, implying its independent nature. We concluded that frequent drinking of SSB increased pancreatic cancer in adults, with highest risk among young people.

Children's and Parents' Marburg Sugar Index (MSI) Values: Are They Comparable?

Studies on children’s nutritional behaviour (CNB) rarely compare children’s answers regarding the frequency of their sugar intake with the respective statements of their parents. Therefore, data from a prevention study were used to analyse this aspect, as well as a potential correlation between Marburg Sugar Index (MSI) values and caries experience of children. The present study based its questionnaire data on CNB and caries data. Pairs of questionnaires filled in separately by children and parents of the participating families were dichotomised by either having completed the diet section entirely (Group A) or in part (Group B). The MSI scores were calculated separately for children and parents. The statistical confidence level was set at α = 0.05 (two-sided). Furthermore, the Pearson correlation coefficient was calculated and tested for “r = 0”. Additionally, a test for equality of the correlations was applied. The number of available questionnaire pairs was 429 in Group A and 400 in Group B. In both groups, significant correlations between children’s and parents’ MSI scores (A: r = 0.301, p < 0.001; B: r = 0.226, p < 0.001) were found. Using Spearman’s Rho, a significant correlation between MSI scores and children’s caries experiences was observed in Group A. MSI scores based on dietary questionnaires can be used to obtain consistent information on children’s CNB provided by the children themselves or their parents. This is true even when the MSI score has to be calculated on the basis of incomplete questionnaires. Questionnaire-based CNB information can improve the effectiveness of individual or group preventive measures supplemented by individually adapted nutritional counselling.

Intakes of nutrients and food categories in Canadian children and adolescents across levels of sugars intake: cross-sectional analyses of the Canadian Community Health Survey 2015 Public Use Microdata File

Dietary recommendations to reduce sugars consumption may influence choices of sugars-containing foods and affect the intake of key micronutrients. We compared intakes of nutrients and food sources stratified by quintiles of total sugars in Canadian children (2-8 y) and adolescents (9-13 y, 14-18 y) using 24-hour dietary recalls from the 2015 Canadian Community Health Survey-Nutrition. Energy intakes did not differ across quintiles of sugars intake. Those with lower sugars intakes (Q1/Q3) generally had higher protein, fat, sodium, niacin, folate, and zinc and lower vitamin C compared with those with the highest sugars intakes (Q5). Q1 also had lower potassium but higher saturated fat compared with Q5. Further, Q1 generally had higher protein, fats, and niacin compared with Q3, while children in Q3 had higher potassium and riboflavin and older adolescents had higher calcium and fibre. Q5 had highest intakes of multiple sugar-containing food categories (e.g., fruit, confectionary, milks, cakes/pies/pastries), with higher sugars-sweetened beverages in adolescents. Q3 had higher fruit, milks, and fruit juice compared with Q1 and lower sugars/syrups/preserves, confectionary, and fruit juices compared with Q5. Certain nutrient-dense food sources of sugars (fruit, milks) may help increase key nutrients (potassium, calcium, fibre) in older adolescents with low sugars intakes. However, in those with the highest sugars intakes, nutrient-poor foods may displace nutrient-dense foods. Novelty: Canadian children and adolescents with lower sugars intake have better intakes of some nutrients. Energy intakes did not differ across sugars intake. Older adolescents with mean intakes of total sugars had better intakes of some key nutrients (potassium, calcium, fibre).

The Power of Women: Does increasing women's parliamentary representation reduce intake of sugar-sweetened beverages among children and adolescents?

OBJECTIVE

Consumption of sugar-sweetened beverages (SSBs) is associated with overweight and obesity in children and adolescents. Although existing research confirms the significance of economic and social factors as determinants of SSB intake, comparative studies on political factors and cross-national analyses are lacking. Research indicates that including women in the process of political decision-making promotes healthcare and child protection. This study examined how women's parliamentary representation influences children's and adolescents' SSB intake compared to adults.

DESIGN

The study used cross-national food and beverage intake data from the Global Dietary Database. The outcome measurement was SSB consumption (g/day) for different population groups. We modeled SSB intake as a function of age groups, women's parliamentary representation at the national level (the independent variable), regime types (the contextual factor), and import tariffs on SSBs (the mediator) using country and time fixed effects regression models.

SETTING

185 countries across three waves from 2005 to 2015.

PARTICIPANTS

Different population groups.

RESULTS

The impact of female representation on reducing SSB consumption is more prevalent in children and adolescents than in adults. Furthermore, the effect of women's parliamentary representation on SSB consumption among children and adolescents is conditional on a country's democratic status. Finally, the marginal effect decreases when import tariffs on SSBs are considered a link in a causal chain. No changes in adult SSB intake are statistically significant.

CONCLUSIONS

The findings suggest that the presence of women in the legislature can have a substantial impact on child and adolescent health.

Sugar-Sweetened Beverages and Symptom Complaints among School-Aged Children: A National Longitudinal Study

The association between sugar-sweetened beverages (SSBs) and symptom complaints among school-aged children remains unclear. Children aged 6−17 years (n = 29,028) were recruited on the basis of a national school-based study. Data collection included two waves: the exposure was the amount and frequency of SSB consumption, collected in the 2013 autumn semester, and outcomes were defined as having clinical symptom complaints after two weeks of observation, collected in the 2014 spring semester. Symptom complaints were defined as fever, cough, headache, loose bowels, vomiting, sore throat, rash, conjunctival congestion, and stomachache. The associations between the amount/frequency of SSBs and symptoms complaints were explored by a general linear model, with adjustments made for socio-demographic and other lifestyle information. Among the 12,454 children (10.32 ± 3.15 years, 48.7% male) in the final analysis, the odds ratio for having symptom complaints (1.46, 95% CI: 1.10−1.95) among children whose SSB consumption was >75 mL/day was significantly higher than that among children who had no SSB consumption. Among children with a daily SSB intake of more than 75 mL, there was a higher risk for symptom complaints. We recommend more support for decreasing SSB consumption among children to minimize negative health outcomes.

Prospective Associations of Sugar-Sweetened Beverage Consumption During Adolescence with Body Composition and Bone Mass at Early Adulthood

BACKGROUND

Adolescents have a higher consumption of sugar-sweetened beverages (SSBs) than other age groups, but little is known of the impact of SSB intake during adolescence on body composition and bone mass in early adulthood.

OBJECTIVES

Associations of SSB intake from 14 to 20 y with fat, lean, and bone mass at 20 y of age were evaluated.

METHODS

Study participants were 1137 offspring (562 females) from the Raine Study. Food intake, including SSB consumption in servings/d (1 serving = 250 mL), was estimated using FFQs at 14, 17, and 20 y of age. DXA scanning at 20 y measured whole body fat mass, lean mass, and bone mineral content (BMC). Using latent class growth analysis, 4 SSB intake trajectory classes were identified: consistently low (n = 540, intakes mostly <0.5 serving/d), increasing (n = 65), decreasing (n = 258), and consistently high (n = 274, intakes mostly >1.3 servings/d).

RESULTS

Median total SSB intake was 0.8, 0.7, and 0.5 serving/d, and median carbonated SSB intake was 0.3, 0.3, and 0.4 serving/d at 14, 17, and 20 y, respectively. Mean ± SD BMI (in kg/m2) was 23.9 ± 4.2 at 20 y. After adjustment for covariates including sex, demographic, energy intake, and maternal factors, individuals with "consistently high" SSB consumption had significantly higher total body fat mass at 20 y than those with "consistently low" consumption (23.3 ± 0.6 compared with 21.2 ± 0.4 kg, P = 0.004), which remained significant after further adjustment for "Healthy" and "Western" dietary patterns (23.2 ± 0.6 compared with 21.2 ± 0.4 kg, P = 0.011). No significant associations were observed between SSB intake trajectory classes and lean body mass or BMC at 20 y.

CONCLUSIONS

In this cohort, consistently higher consumption of SSBs in adolescence and early adulthood are associated with increased fat mass but not with bone mass at 20 y of age.

Race, Ethnicity, and Neighborhood Food Environment Are Associated with Adolescent Sugary Drink Consumption During a 5-Year Community Campaign

Background

A multi-level county-wide campaign to reduce sugary drink consumption was associated with significant decreases in retail sales of soda and fruit drinks. The aim of the current study was to examine changes in adolescent beverage consumption during the campaign by race/ethnicity and neighborhood food environment.

Methods

Beverage consumption among adolescents was evaluated at four time points in a repeated cross-sectional survey of a racially and ethnically diverse sample of sixth graders (N = 13,129) from public middle schools in the county. Each school’s surrounding attendance zone (i.e., neighborhoods where students live) was characterized as providing high or low exposure to unhealthy food retail (e.g., convenience stores, fast-food restaurants). Logistic and multiple linear regression models were used to evaluate changes in beverage consumption over time by student race/ethnicity and high versus low unhealthy food exposure.

Results

Over the 5 years, there were significant declines in the overall share of students who reported daily sugary drink consumption (49.4 to 36.9%) and their reported daily calories from these products (220 to 158 calories). However, disparities were observed, with higher levels of consumption among Black and Hispanic youth and among youth living in neighborhoods with more unhealthy food retail. Notably, Black students living in healthier neighborhood food environments reported significant decreases in daily consumption and calories after 5 years, while Black students living in neighborhoods with more convenience stores and fast-food outlets did not.

Conclusion

These findings suggest that both race/ethnicity and neighborhood food environments are important considerations when designing interventions to reduce sugary drink consumption among adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40615-021-01074-9.

Sugar-Sweetened Beverage Consumption Status and Its Association with Childhood Obesity among Chinese Children Aged 6-17 Years

Objective: There is a remarkable growth in sugar-sweetened (SSB) production and obesity prevalence among school-aged children in China. This paper describes SSB consumption and its association with obesity among Chinese children aged 6–17 years in 2012. Methods: in total, 25,553 children aged 6~17 years enrolled in the China Nutrition and Health Surveillance 2010–2013 were included in this study. Data of SSB consumption frequency and quantity were obtained from a food frequency questionnaire, and the children’s nutritional status was assessed. Multivariate logistic regression was used to evaluate the association between SSB consumption and obesity status. Results: SSB intake was estimated as 181.0 g/day, occurring 2.2 times/week. Older children, males, children from urban areas, and children with higher socioeconomic status were more likely to consume SSBs. Children who consumed SSBs 1~<5 times/week (11.7%) and >5 times/week (12.9%) were more likely to be overweight/obesity than those who consumed SSBs less than once/week. Conclusion: SSB consumption was common among Chinese school-aged children, especially among males, older children, and children from urban areas. High consumption of SSBs was associated with a higher prevalence of overweight/obesity. Actions and plans are required to reduce SSB consumption and control childhood obesity in China.

Effects of nutrition intervention strategies in the primary prevention of overweight and obesity in school settings: a protocol for a systematic review and network meta-analysis

BACKGROUND

Overweight and obesity in children and adolescents are major public health challenges affecting quality of life and representing important risk factors in the development of non-communicable diseases. School environments provide great possibilities for the primary prevention of overweight and obesity and different school-based nutrition interventions are available. However, existing research on school-based nutrition interventions has important limitations and no network meta-analysis (NMA) has been performed yet to compare all available interventions. Therefore, the present research project aims to investigate the impact of different nutrition interventions in the school setting by comparing and ranking them using NMA methodology.

METHODS/DESIGN

A systematic literature search will be performed in 11 electronic databases (PubMed, the Cochrane Library, Web of Science, ERIC, PsycINFO, CAB Abstracts, Campbell Library, BiblioMap EPPI, Australian Education Index, Joanna Briggs Institute Evidence-Based Practice Database and Practice-based Evidence in Nutrition Database). Parallel or cluster randomized controlled trials (RCTs) meeting the following criteria will be included: (1) generally healthy school students aged 4-18 years, (2) school-based intervention with ≥ 1 nutrition component, and (3) assessed anthropometric (overweight/obesity risk, body weight change, weight Z-score, [standardized] body mass index, body fat, waist circumference) and/or diet-quality measures (daily intake of fruits and vegetables, fat, and sugar-sweetened beverages). Random effects pairwise and NMA will be performed for these outcomes and surface under the cumulative ranking curve (SUCRA) estimated (P-score). Where possible, component NMA (CNMA) will be used additionally. Subgroup analyses are carried out for intervention duration, gender, age of school students, socioeconomic status, and geographical location, and sensitivity analyses by excluding high risk of bias RCTs.

DISCUSSION

This systematic review and NMA will be the first to both directly and indirectly compare and rank different school-based nutrition interventions for the primary prevention of overweight and obesity in childhood and adolescence. Our analyses will provide important insights about the effects of the different interventions and show which are the most promising. The results of our study can help inform the design of new studies and will be of value to anyone interested in developing successful, evidence-based nutrition interventions in school settings.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020220451 .

Sex- and weight-specific changes in the frequency of sweet treat consumption during early adolescence: a longitudinal study

The transition from childhood to adolescence is a sensitive period, triggering changes in health- and weight-related behaviours including eating habits which likely vary between girls and boys. We aimed to characterise the changes in the frequency of consumption of select sugary foods and drinks ('sweet treats') among 4237 Finnish girls and boys during a 2-year follow-up period. Additionally, we examined four subgroups: children whose weight or waist normalised as well as children whose weight or waist circumference increased during follow-up. An FFQ was completed at 11·1 (sd 0·9) and again at 13·4 (sd 1·1) years of age. A sum variable sweet treat index (STI, range 0-84) captured the weekly consumption frequencies of sweet treats. From baseline to follow-up, the mean STI decreased among girls from 7·1 (95 % CI 6·9, 7·3) to 6·0 (95 % CI 5·9, 6·2) (P < 0·001) and boys from 8·5 (95 % CI 8·3, 8·8) to 7·8 (95 % CI 7·6, 7·8) (P < 0·001), although both sexes increased their chocolate/sweets consumption: girls from 1·3 (95 % CI 1·3, 1·4) to 1·6 (95 % CI 1·5, 1·6) (P < 0·001) and boys from 1·4 (95 % CI 1·3, 1·4) to 1·6 (95 % CI 1·6, 1·7) (P < 0·001), and boys increased their soft drink consumption from 1·4 (95 % CI 1·3, 1·4) to 1·5 (95 % CI 1·4, 1·5) (P = 0·020). We found similar decreases in both the weight and waist subgroups. To conclude, the total frequency of consumption of sweet treats decreased during early adolescence. A similar trend across subgroups suggests that the frequency of consumption of sweet treats is unrelated to becoming overweight.

Understanding sweet-liking phenotypes and their implications for obesity: Narrative review and future directions

Building on a series of recent studies that challenge the universality of sweet liking, here we review the evidence for multiple sweet-liking phenotypes which strongly suggest, humans fall into three hedonic response patterns: extreme sweet likers (ESL), where liking increases with sweetness, moderate sweet likers (MSL), who like moderate but not intense sweetness, and sweet dislikers (SD), who show increasing aversion as sweetness increases. This review contrasts how these phenotypes differ in body size and composition, dietary intake and behavioural measures to test the widely held view that sweet liking may be a key driver of obesity. Apart from increased consumption of sugar-sweetened beverages in ESL, we found no clear evidence that sweet liking was associated with obesity and actually found some evidence that SD, rather than ESL, may have slightly higher body fat. We conclude that ESL may have heightened awareness of internal appetite cues that could protect against overconsumption and increased sensitivity to wider reward. We note many gaps in knowledge and the need for future studies to contrast these phenotypes in terms of genetics, neural processing of reward and broader measures of behaviour. There is also the need for more extensive longitudinal studies to determine the extent to which these phenotypes are modified by exposure to sweet stimuli in the context of the obesogenic environment.

A Systematic Scoping Review of Media Campaigns to Develop a Typology to Evaluate Their Collective Impact on Promoting Healthy Hydration Behaviors and Reducing Sugary Beverage Health Risks

Interventions to discourage sugary beverages and encourage water consumption have produced modest and unsustainable behavioral changes to reduce obesity and noncommunicable disease risks. This systematic scoping review examined media campaigns to develop a typology to support healthy hydration nonalcoholic beverage behaviors. Our three-step methodology included the following: (1) review and summarize expert-recommended healthy beverage guidelines; (2) review six English-language electronic databases guided by PRISMA to describe existing campaign types by issue, goal and underlying theory; and (3) develop a media campaign typology to support policies, systems and environments to encourage healthy hydration behaviors. Results showed no international consensus for healthy beverage guidelines, though we describe expert-recommended healthy beverage guidelines for the United States. Of 909 records identified, we included 24 articles describing distinct media campaigns and nine sources that defined models, schemes or taxonomies. The final media campaign typology included: (1) corporate advertising, marketing or entertainment; (2) corporate social responsibility, public relations/cause marketing; (3) social marketing; (4) public information, awareness, education/ health promotion; (5) media advocacy/countermarketing; and (6) political or public policy. This proof-of-concept media campaign typology can be used to evaluate their collective impact and support for a social change movement to reduce sugary beverage health risks and to encourage healthy hydration behaviors.