Environmental Interventions to Reduce the Consumption of Sugar-Sweetened Beverages: Abridged Cochrane Systematic Review

An SMS chatbot digital educational program to increase healthy eating behaviors in adolescence: A multifactorial randomized controlled trial among 7,890 participants in the Danish National Birth Cohort

BACKGROUND

Few cost-effective strategies to shift dietary habits of populations in a healthier direction have been identified. We examined if participating in a chatbot health education program transmitted by Short Messages Service ("SMS-program") could improve adolescent dietary behaviors and body weight trajectories. We also explored possible added effects of maternal or peer involvement.

METHODS AND FINDINGS

We conducted a randomized controlled trial (RCT) among adolescents from the Danish National Birth Cohort (DNBC). Eligible were adolescents who during 2015 to 2016 at age 14 years had completed a questionnaire assessing height, weight, and dietary habits. Two thirds were offered participation in an SMS-program, whereas 1/3 ("non-SMS group") received no offer. The SMS program aimed to improve 3 key dietary intake behaviors: sugar-sweetened beverages (SSBs), fruit and vegetables (FV), and fish. The offered programs had 3 factorially randomized schemes; the aims of these were to test effect of asking the mother or a friend to also participate in the health promotion program, and to test the effect of a 4-week individually tailored SMS program against the full 12-week SMS program targeting all 3 dietary factors. Height and weight and intakes of SSB, FV, and fish were assessed twice by a smartphone-based abbreviated dietary questionnaire completed at 6 months (m) and 18 m follow-up. Main outcome measures were (1) body mass index (BMI) z-score; and (2) an abbreviated Healthy Eating Index (mini-HEI, 1 m window, as mean of z-scores for SSB, FV, and fish). Among the 7,890 randomized adolescents, 5,260 were assigned to any SMS program; 63% (3,338) joined the offered program. Among the 7,890 randomized, 74% (5,853) and 68% (5,370) responded to follow-ups at 6 m and 18 m, respectively. Effects were estimated by intention-to-treat (ITT) analyses and inverse probability weighted per-protocol (IPW-PP) analyses excluding adolescents who did not join the program. Mean (standard deviation (SD)) mini-HEI at baseline, 6 m and 18 m was -0.01 (0.64), 0.01 (0.59), and -0.01 (0.59), respectively. In ITT-analyses, no effects were observed, at any time point, in those who had received any SMS program compared to the non-SMS group, on BMI z-score (6 m: -0.010 [95% confidence interval (CI) -0.035, 0.015]; p = 0.442, 18 m: 0.002 [95% CI -0.029, 0.033]; p = 0.901) or mini-HEI (6 m: 0.016 [95% CI -0.011, 0.043]; p = 0.253, 18m: -0.016 [95% CI -0.045, 0.013]; p = 0.286). In IPW-PP analyses, at 6 m, a small decrease in BMI z-score (-0.030 [95% CI -0.057, -0.003]; p = 0.032) was observed, whereas no significant effect was observed in mini-HEI (0.027 [95% CI -0.002, 0.056]; p = 0.072), among those who had received any SMS program compared to the non-SMS group. At 18 m, no associations were observed (BMI z-score: -0.006 [95% CI -0.039, 0.027]; p = 0.724, and mini-HEI: -0.005 [95% CI -0.036, 0.026]; p = 0.755). The main limitations of the study were that DNBC participants, though derived from the general population, tend to have higher socioeconomic status than average, and that outcome measures were self-reported.

CONCLUSIONS

In this study, a chatbot health education program delivered through an SMS program had no effect on dietary habits or weight trajectories in ITT analyses. However, IPW-PP-analyses, based on those 63% who had joined the offered SMS program, suggested modest improvements in weight development at 6 m, which had faded at 18 m. Future research should focus on developing gender-specific messaging programs including "booster" messages to obtain sustained engagement.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02809196 https://clinicaltrials.gov/study/NCT02809196.

Student and caregiver acceptability of a school-based intervention to improve sugar-sweetened beverage behaviors: a mixed methods study

Kids SIPsmartER is a 6-month behavioral and health literacy intervention effective at reducing sugar-sweetened beverage (SSB) intake among middle school students and their caregivers in the rural Appalachian region. This exploratory mixed methods study utilized a convergent parallel design to assess participant acceptability of a school-based curriculum for students and a text messaging program for caregivers. Acceptability was assessed using surveys (873 students and 453 caregivers), five focus groups (34 students) and telephone interviews (22 caregivers). Quantitative data were analyzed descriptively, and qualitative data were content coded. On a 5-point scale, average quantitative survey acceptability ratings ranged from 2.7 to 3.3 among three student-rated questions and 4.1 to 4.2 among four caregiver-rated questions. Qualitative focus group findings suggested that students preferred curricular activities that were hands-on and involved social interaction, while caregiver interview results showed high acceptability of the text messaging program's design, including usability, content messages and personalization. Students and caregivers reported similar program benefits: increased knowledge of SSBs and health risks, increased awareness of SSB behaviors and support to make beverage behavior changes. Results from this study can be used to understand Kids SIPsmartER's effectiveness data, communicate the intervention's acceptability with stakeholders and plan for future implementation studies.

Lifestyle interventions to change trajectories of obesity-related cardiovascular risk from childhood onset to manifestation in adulthood: a joint scientific statement of the task force for childhood health of the European Association of Preventive Cardiology and the European Childhood Obesity Group

There is an immediate need to optimize cardiovascular (CV) risk management and primary prevention of childhood obesity to timely and more effectively combat the health hazard and socioeconomic burden of CV disease from childhood development to adulthood manifestation. Optimizing screening programs and risk management strategies for obesity-related CV risk in childhood has high potential to change disease trajectories into adulthood. Building on a holistic view on the aetiology of childhood obesity, this document reviews current concepts in primary prevention and risk management strategies by lifestyle interventions. As an additional objective, this scientific statement addresses the high potential for reversibility of CV risk in childhood and comments on the use of modern surrogate markers beyond monitoring weight and body composition. This scientific statement also highlights the clinical importance of quantifying CV risk trajectories and discusses the remaining research gaps and challenges to better promote childhood health in a population-based approach. Finally, this document provides an overview on the lessons to be learned from the presented evidence and identifies key barriers to be targeted by researchers, clinicians, and policymakers to put into practice more effective primary prevention strategies for childhood obesity early in life to combat the burden of CV disease later in life.

Effectiveness of a School Drinking Water Promotion and Access Program for Overweight Prevention

BACKGROUND AND OBJECTIVE

Drinking water promotion and access shows promise for preventing weight gain. This study evaluated the impact of Water First, a school-based water promotion and access intervention on changes in overweight.

METHODS

Low-income, ethnically diverse elementary schools in California's Bay Area were cluster-randomized to intervention and control groups. Water First includes classroom lessons, water stations, and schoolwide water promotion over 1 school year. The primary outcome was overweight prevalence (BMI-for-age-and-sex ≥85th percentile). Students (n = 1249) in 56 fourth-grade classes in 18 schools (9 intervention, 9 control) from 2016 to 2019 participated in evaluation at baseline, 7, and 15 months. Data collection was interrupted in 8 additional recruited schools because of coronavirus disease 2019.

RESULTS

Of 1262 students from 18 schools, 1249 (47.4% girls; mean [SD] age, 9.6 [0.4] years; 63.4% Hispanic) were recruited. From baseline to 7 months, there was no significant difference in changes in overweight prevalence in intervention schools (-0.2%) compared to control schools (-0.4%) (adjusted ratio of odds ratios [ORs]: 0.7 [confidence interval (CI): 0.2-2.9] P = 0.68). From baseline to 15-months, increases in overweight prevalence were significantly greater in control schools (3.7%) compared to intervention schools (0.5%). At 15 months, intervention students had a significantly lower change in overweight prevalence (adjusted ratio of ORs: 0.1 [CI: 0.03-0.7] P = .017) compared to control students. There were no intervention effects for obesity prevalence.

CONCLUSIONS

Water First prevented increases in the prevalence of overweight, but not obesity, in elementary school students.

Community Solutions to Increase the Healthfulness of Grocery Stores: Perspectives of Immigrant Parents

Grocery store environments are recognized as one of the most crucial community settings for developing and maintaining healthy nutritional behaviors in children. This is especially true for disadvantaged ethnic minority families, such as immigrants, who reside in the Detroit Metropolitan area and have historically experienced inequities that result in poor health outcomes. Rates of obesity and type II diabetes have affected Detroit 38% more than the rest of the state and nationwide. In 2019, almost 54% of children aged 0-17 in Metro Detroit lived in poverty, and 21.6% experienced food insecurity, compared with the state level of 14.2%. Moreover, nearly 50% of ethnic minority children in Metro Detroit consume sports drinks, and 70% consume soda or pop in an average week. The primary purpose of this study was to explore immigrant parents' perspectives on (1) how in-store Sugar-Sweetened Beverage (SSB) marketing impacts the purchasing behaviors of parents and the eating behaviors of toddlers, and the secondary objective was to (2) determine strategies to reduce SSB purchases and consumption within grocery environments from the viewpoints of immigrant parents. A qualitative multiple-case study design was used to achieve the aims of this study. Semi-structured individual interviews were completed with 18 immigrant parents of children aged 2 to 5 years old who were consumers in 30 independently owned full-service grocery stores within the immigrant enclaves of Detroit, Dearborn, Hamtramck, and Warren, Michigan. Three key thematic categories emerged from the parents' narratives. These themes were: (1) non-supportive grocery store environments; (2) acculturation to the American food environment; and (3) strategies to support reduced SSB consumption among young immigrant children. The findings of this study revealed widespread SSB marketing targeting toddlers within the participating independently owned grocery stores. Even if families with young children practiced healthy nutritional behaviors, the prices, placements, and promotion of SSBs were challenges to establishing and sustaining these healthy eating habits. The parents believed that planning and implementing retail-based strategies in collaboration with families and considering families' actual demands would assist in managing children's eating patterns and reducing early childhood obesity.

City features related to obesity in preschool children: a cross-sectional analysis of 159 cities in six Latin American countries

Background

Childhood obesity is a rising global health problem. The rapid urbanization experienced in Latin America might impact childhood obesity through different pathways involving urban built and social features of cities. We aimed to evaluate the association between built and social environment features of cities and childhood obesity across countries and cities in Latin America.

Methods

Cross-sectional analysis of data from 20,040 children aged 1-5 years living in 159 large cities in six Latin American countries. We used individual-level anthropometric data for excess weight (overweight or obesity) from health surveys that could be linked to city-level data. City and sub-city level exposures included the social environment (living conditions, service provision and educational attainment) and the built environment (fragmentation, isolation, presence of mass transit, population density, intersection density and percent greenness). Multi-level logistic models were used to explore associations between city features and excess weight, adjusting for age, sex, and head of household education.

Findings

The overall prevalence of excess weight among preschool children was 8% but varied substantially between and within countries, ranging from 4% to 25%. Our analysis showed that 97% of the variability was between individuals within sub-city units and around 3% of the variance in z-scores of weight for height was explained by the city and sub-city levels. At the city-level, a higher distance between urban patches (isolation, per 1 SD increase) was associated with lower odds of excess weight (OR 0.90, 95% CI 0.82-0.99). Higher sub-city education was also associated with lower odds of excess weight, but better sub-city living conditions were associated with higher odds of excess weight.

Interpretation

Built and social environment features are related to excess weight in preschool children. Our evidence from a wide range of large Latin American cities suggests that urban health interventions may be suitable alternatives towards attaining the goal of reducing excess weight early in the life course.

Funding

The SALURBAL project (Salud Urbana en América Latina, Urban Health in Latin America) is funded by Wellcome [205177/Z/16/Z].

Retail Soda Purchases Decrease and Water Purchases Increase: 6-Year Results From a Community-Based Beverage Campaign

Introduction

This study aimed to document the long-term impacts on beverage sales of a 6-year intervention campaign to reduce consumption of sugar-sweetened beverages.

Methods

In 2013, a multicomponent intervention campaign designed to reduce the intake of sugary drinks was launched in Howard County, Maryland. A difference-in-differences regression approach was used to compare data on Howard County supermarket beverage sales (in ounces) from 2013 to 2018 with a set of control supermarkets. Outcome variables were average weekly sales by store of top brands of sugar-sweetened beverages (regular soda, sports drinks, fruit drinks) as well as diet soda and 100% juice. Trends in the sales of water products from 2016 to 2018 were estimated separately using a linear regression model.

Results

In Howard County, the sales of regular soda, fruit drinks, and 100% juice decreased significantly more than predicted each year. These changes correspond to a 29.7% decrease in sales for regular soda, a 7.5% decrease for fruit drinks, and a 33.5% drop for 100% juice between 2012 and 2018 in Howard County stores. There was a significant trend such that the net reduction in regular soda sales in Howard County stores became larger over time. The amount of plain water sold in Howard County increased significantly from 2016 to 2018.

Conclusions

Multicomponent efforts by local government, nonprofit organizations, and other community-based organizations are needed to decrease sugar-sweetened beverage consumption at the population level. Substantial and sustained improvements in retail beverage sales can be achieved through coordinated messaging, community organizing, and targeted advocacy for policy changes.

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.

Trajectories of Sugar Consumption and Dental Caries in Early Childhood

This study verifies the association between the trajectory of sugar consumption and dental caries in the 2015 Pelotas Birth Cohort in Pelotas, Brazil. It was conducted with data from the follow-ups at 3, 12, 24, and 48 mo from the 2015 Birth Cohort, which included 4,275 children born alive in hospitals in Pelotas. Data collection included standardized questionnaires for first caregivers applied by trained interviewers at all follow-ups. Exposure was the trajectory of sugar consumption from 3 to 48 mo (always low, always intermediate, increasing, and always high), obtained by group-based trajectory modeling. The outcome of this study was dental caries, obtained through clinical examination performed by calibrated dentists at 48 mo of age. Socioeconomic conditions and oral health instruction from a health professional during the first 4 y of life were included in the analysis as potential confounders. Prevalence ratios and their 95% confidence intervals were provided from generalized estimating equations with a log-Poisson with robust variance specification. In total, 3,654 (91.1%) children participated in the survey at 48 mo, and 2,806 children had complete data for the analyzes performed. Of these, 1,012 (36.1%; 95% confidence interval [CI], 34.3-37.8) experienced caries, and 723 (25.8%; 95% CI, 24.2-27.4) had cavitated caries. Regarding cavitated caries, the prevalence was 1.48 times higher in the group with increasing sugar consumption than children with always low consumption. There is an association between the trajectory of sugar consumption and dental caries at 48 mo. Children with increasing and always high sugar consumption have the highest prevalence of caries.

Molecular aspects of fructose metabolism and metabolic disease

Excessive sugar consumption is increasingly considered as a contributor to the emerging epidemics of obesity and the associated cardiometabolic disease. Sugar is added to the diet in the form of sucrose or high-fructose corn syrup, both of which comprise nearly equal amounts of glucose and fructose. The unique aspects of fructose metabolism and properties of fructose-derived metabolites allow for fructose to serve as a physiological signal of normal dietary sugar consumption. However, when fructose is consumed in excess, these unique properties may contribute to the pathogenesis of cardiometabolic disease. Here, we review the biochemistry, genetics, and physiology of fructose metabolism and consider mechanisms by which excessive fructose consumption may contribute to metabolic disease. Lastly, we consider new therapeutic options for the treatment of metabolic disease based upon this knowledge.

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.

Nutritional Status and Oral Frailty: A Community Based Study

Compromised oral health can alter food choices. Poor masticatory function leads to imbalanced food intake and undesirable nutritional status. The associations among nutritional status, oral health behavior, and self-assessed oral functions status were investigated using a community-based survey. In total, 701 subjects more than 50 years old living Ebina city located southwest of the capital Tokyo were investigated. The number of remaining teeth was counted by dental hygienists. Oral health behavior and self-assessed oral functions were evaluated by oral frailty checklist. Nutritional status was evaluated by the brief-type self-administered diet history questionnaire using Dietary Reference Intakes for Japanese as reference. More than 80% of subjects’ intakes of vitamin B₁₂, pantothenic acid, copper, and proteins were sufficient. In contrast, only 19% of subjects’ intake of vitamin A was sufficient and 35.5% for vitamin B₁. More than 90% of subjects’ intakes of vitamin D and vitamin K were sufficient. Only 35.5% of subjects’ intakes of dietary fiber were sufficient. Overall, 88.9% of subjects had excess salt. The number of remaining teeth was not correlated with nutritional intakes. Oral health behavior significantly correlated with nutritional intakes. Oral functions are important for food choice; however, oral functions were not directly correlated with nutritional intakes. Comprehensive health instructions including nutrition and oral health education is necessary for health promotion.