Correlates of Sugar-Sweetened Beverages Purchased for Children at Fast-Food Restaurants

Prevalence of Sugar-Sweetened Food Consumption in Rural Bangladeshi Children Aged 6-24 Months

BACKGROUND

While the prevalence of undernutrition in children has decreased in many low- and middle-income countries since the 1990s, prevalences of overweight and obesity have increased. Frequent consumption of sugar-sweetened food might have contributed to this change, although very little is known about sugar-sweetened food consumption in early life.

OBJECTIVES

The objective of this study was to explore the associations between individual, household, and maternal factors and the prevalence of sugar-sweetened food consumption in 6- to 24-month-old children in Bangladesh.

METHODS

Multistage sampling was used to select households with children aged 6-24 months in rural Chatmohar, a subdistrict of Bangladesh (n = 1635). Research assistants conducted a 24-hour qualitative dietary recall questionnaire with the enrolled child's primary caregiver to measure maternal and child dietary patterns. We examined factors associated with the prevalence of child sugar-sweetened food consumption with multivariate logistic regression models. We conducted tests of heterogeneity to explore differential associations between the child sugar-sweetened food consumption prevalence and household income by maternal nutrition knowledge and wealth.

RESULTS

Primary caregivers reported that 62% of toddlers had consumed sugar-sweetened food in the past 24 hours. A higher prevalence of child sugar-sweetened food consumption was associated with both a higher dietary diversity score (OR, 1.19; 95% CI, 1.09-1.29) and a higher prevalence of maternal sugar-sweetened food consumption (OR, 2.54; 95% CI, 1.97-3.28). At higher levels of maternal nutrition knowledge and wealth, more household income was associated with a lower prevalence of child sugar-sweetened food consumption.

CONCLUSIONS

Almost two-thirds of 6- to 24-month-old children in rural Chatmohar, Bangladesh, had consumed sugar-sweetened food in the last day. This is a high and concerning prevalence, and the associated factors identified in this study should be investigated further to identify potential areas of intervention to decrease the prevalence of child sugar consumption in Bangladesh.

Effectiveness of mobile application on changing weight, healthy eating habits, and quality of life in children and adolescents with obesity: a randomized controlled trial

BACKGROUND

A technology-based intervention, such as a mobile application, was a growing interest and potentially effective modality for treating obesity. The study aimed to evaluate the effectiveness of the OBEST, a new mobile/tablet-based application in reducing weight and encouraging healthy eating behaviors and quality of life in children with obesity. The application could assist healthcare professionals to treat children and adolescents with obesity.

METHODS

A randomized controlled trial was conducted in the hospital and school settings in Chiang Mai, Thailand. Seventy-seven children and adolescents with obesity were randomized into two groups; one received standard care combined with the OBEST application, and the other received only standard care. The outcomes were changes in weight, healthy eating behaviors, and quality of life assessed by the Pediatric Quality of Life Inventory (PedsQL) from baseline to six-month follow-up between the two groups.

RESULTS

The results showed that the intervention group reduced more body mass index (BMI) and had a higher number of participants engaging in healthy eating behaviors than the standard care group but did not reach a statistically significant level, except for less frequent consumption of fast food. The participants in the intervention group had 4.5 times higher odds of decreased engaging in fast-food consumption than the standard care group at 6 months follow-up (odds ratio, 4.5 [95% CI, 1.41 to 14.35]). There were no statistically significant changes in PedsQL scores over 6 months in between groups.

CONCLUSIONS

The current study was unable to detect a significant effect of the OBEST application as an adjunct tool to the standard treatment on reducing weight in obese children and adolescents. However, the mobile application might help to increase engaging in healthy eating behaviors. Further studies with a larger sample are needed to confirm our findings.

TRIAL REGISTRATION

The trial was retrospectively registered at the Thai Clinical Trials Registry (trial registration number: TCTR20200604008 , on June 4, 2020).

Voluntary healthier kids' meals policies: Are caregivers choosing kids' meals and healthier items for their child?

BACKGROUND

Children's fast-food consumption increases risks for obesity and other diet-related diseases. To address concerns, from 2010 to 2016 U.S. fast-food restaurants implemented voluntary policies to offer healthier drinks and/or sides with kids' meals.

OBJECTIVES

Examine the effectiveness of voluntary kids' meal policies.

METHODS

Online repeated cross-sectional survey (2010, 2013, 2016) of U.S. caregivers (N = 2093) who purchased fast-food for their child (2-11 years) in the past week. Logistic regression examined associations between healthier kids' meal policy implementation and caregivers' purchases of kids' meals and selection of healthier sides and drinks. Separate models investigated caregivers' attitudes about McDonald's kids' meal items.

RESULTS

Overall, 55% of caregivers reported choosing a kids' meal for their child, and approximately one-half of those caregivers selected a healthier drink and/or side. Healthier kids' meal policy implementation was associated with increased selection of healthier sides, but not healthier drinks or choice of kids' meals over higher-calorie menu items. Child's age, caregiver gender and visit frequency were significant in most models. Caregivers' perceptions that their child(ren) like healthier drinks and sides were positively associated with selection of those items.

CONCLUSIONS

Existing healthier kids' meal policies may not improve children's fast-food consumption. Public health initiatives should examine more effective alternatives.

Baseline Assessment of Children's Meals and Healthy Beverage Options Prior to a State-Level Healthy Default Beverage (HDB) Law

In January 2020, Hawai'i became the second state with a healthy default beverage (HDB) law, requiring restaurants to offer HDBs with their children's meals. This observational study presents baseline characteristics of restaurants with a children's menu and meal. The study describes pre-law beverage options to inform future HDB policy language, implementation, and evaluation. Between November and December 2019, data were collected from a statewide sample of unique restaurants (N = 383) with health inspection permits. Restaurants were assessed separately for a children's menu and meal using website reviews, telephone calls, and in-person visits. Meals were evaluated for pre-law beverage type and compliance. Logistic regression was used to estimate the likelihood of having a children's menu and meal. Most of the restaurants were full-service (70.2%) and non-chains (67.9%). While 49.3% of restaurants had a children's menu, only 16.7% had a children's meal. Significant predictors of having a children's menu were being full-service, national/international or local chains, neighbor island (non-Honolulu) locations, and hotel locations. Only being a national/international chain significantly predicted having a children's meal. Although 35.9% of children's meals offered a non-sugar-sweetened beverage (SSB) option, only 3.1% offered law-compliant beverages. Inclusion of an SSB default option (60.9%) and not specifying the type of default beverage were the predominant factors for pre-law non-compliance. Results support the need for HDB regulations, especially for national/international chains, which were most likely to have children's meals, and provide data to inform policies in other jurisdictions.

An online randomized trial of healthy default beverages and unhealthy beverage restrictions on children's menus

Several U.S. jurisdictions have adopted policies requiring healthy beverage defaults on children's menus, but it is unknown whether such policies or restrictions leads to fewer calories ordered. We recruited 479 caregivers of children for an online choice experiment and instructed participants to order dinner for their youngest child (2-6 years) from two restaurant menus. Participants were randomly assigned to one type of menu: 1) standard beverages on children's menus (Control; n = 155); 2) healthy beverages on children's menus (water, milk, or 100% juice), with unhealthy beverages available as substitutions (Default; n = 162); or 3) healthy beverages on children's menus, with no unhealthy beverage substitutions (Restriction; n = 162). We used linear regression with bootstrapping to examine differences between conditions in calories ordered from beverages. Secondary outcomes included percent of participants ordering unhealthy beverages (full-calorie soda, diet soda, and/or sugar-sweetened fruit drinks) and calories from unhealthy beverages. Calories ordered from beverages did not differ across conditions at Chili's [Default: 97.6 (SD = 69.8); p = 0.82; Restriction: 102.7 (SD = 71.5); p = 0.99; Control: 99.4 (SD = 72.7)] or McDonald's [Default: 90.2 (SD = 89.1); p = 0.55; Restriction: 89.0 (SD = 81.0); p = 0.94; Control: 96.5 (SD = 95.2)]. There were no differences in the percent of orders or calories ordered from unhealthy beverages. Though Restriction participants ordered fewer calories from full-calorie soda [(3.0 (SD = 21.6)] relative to Control participants [13.4 (SD = 52.1); p = 0.04)] at Chili's, we observed no such difference between Default and Control participants, or across McDonald's conditions. Overall, there was no effect of healthy default beverages or restrictions in reducing total calories ordered from unhealthy beverages for children in our experiment.

A Comparison of Maternal Health Status and Weight-Related Cognitions, Behaviors, and Home Environments by Race/Ethnicity

This cross-sectional study compared weight-related cognitions, behaviors, and home environments of 568 mothers of young children (ages 2 to <9 years) by racial/ethnic group. Maternal health status was good and did not differ by race/ethnicity. Mothers were somewhat confident in their ability to promote healthy physical activity and eating behaviors in their children, with White and Asian mothers having greater confidence than Hispanic mothers. Mothers had low physical activity, with Hispanic mothers getting more sedentary screentime than White and Asian mothers. Mothers' dietary intake did not differ. Modeling of healthful behaviors was more frequent in White than Hispanic mothers. Asian mothers tended to use non-recommended feeding patterns more than White, Hispanic, and Black mothers. Children's physical activity and screentime did not differ by race/ethnicity. Asian children tended to drink less sugar-sweetened beverages and more milk than counterparts. All reported frequent family meals, with Hispanic mothers reporting more family meals eaten in less healthful locations. Household food environments did not differ. However, White mothers reported greater access to physical activity space and supports than Hispanic mothers. Race/ethnicity may link with maternal weight-related cognitions, behaviors, and home environments and thus can help inform the development of interventions tailored by race/ethnicity.

Meal deals, combos and bundling: the impact on the nutrition composition of children's meals in restaurants

Increased consumption of food outside the home means that the nutritional content of meals served in restaurants now makes a significant contribution to overall diet. Children's menus in restaurants, usually aimed at those aged 10 years and younger, are frequently high in energy, fat, salt, sugar and lack variety. The food and drink on children's menus are often bundled together as a combo or meal deal that may be convenient to order and sometimes, but not always, cheaper. Bundling has the potential to add additional foods that may not have been selected individually thus increasing the amount ordered and consumed. Substituting some meal deal items for healthier options has the potential to make it easier to eat well when eating outside the home and improve dietary intakes. However, the impact of such measures on child health has yet to be fully explored.

Recent progress in children's meals law in restaurants in Baltimore City and California State: Making a healthy beverage option the default choice

In July 2018, Baltimore became the largest US city to prohibit restaurants from including sugar-sweetened beverages on kids' menus. In September 2018, California made history by becoming the first US state to require either water or milk as the default beverage with children's meals at all restaurants. Supporters of children's meals laws view them as helping to change the culture of health on beverage preferences and subtly influencing the choices of patrons. Using subtle methods of influencing children's beverage choices at restaurants, or nudges, will not on its own eradicate childhood obesity. However, the law aims to make healthier choices easier options and to influence people's choices in predictable ways without restricting their options. Evidence from a wide range of fields shows that people tend to stick with defaults and that setting beneficial defaults has high rates of acceptability. The laws in Baltimore and California, along with the other jurisdictions that have passed similar legislation, reflect a growing understanding - among restaurant owners, community members and policymakers alike - of the importance of feeding children healthy meals. They also signal that making healthier beverages the default option on children's menus is gaining strength in the US. Cities and states across the country should consider enacting similar laws as part of a greater public health initiative to combat the childhood obesity epidemic.

The caries-related cost and effects of a tax on sugar-sweetened beverages

OBJECTIVES

While taxes on sugar-sweetened beverages (SSBs) have frequently been proposed to reduce non-communicable diseases like obesity and type 2 diabetes, relatively little is known about the caries-related impacts of SSB taxation. We assessed the effect of a 20% ad valorem tax on SSBs on dental caries and related treatment costs, specifically taking into account that consumers may switch from SSBs to other (non-taxed) sugar-containing drinks.

STUDY DESIGN

Cost-effectiveness analysis.

METHODS

A tooth-level Markov model was developed to evaluate the cost and effects of SSB taxation. Tax-related changes in sugar consumption were calculated using available evidence on SSBs price and cross-price elasticities, thereby taking changes in drinks consumption behaviors into account. The model was used to establish lifetime disease-free tooth years, caries lesions prevented, caries-related treatment costs avoided, tax revenues, and administrative costs (reference case: the Netherlands). Deterministic and probabilistic sensitivity analyses were performed to address uncertainties.

RESULTS

A 20% SSB taxation would result in an average of 2.13 (95% uncertainty interval [UI] 2.12-2.13) caries-free tooth years per person and, on population level, prevention of 1,030,163 (95% UI 1,027,903-1,032,423) caries lesions. The intervention was found to save an aggregate total of € 159.01 (95% UI 158.67-159.35) million in terms of dental care expenditures. The estimated lifetime tax revenues (€3.49billion) were larger than the administrative costs for taxation (€37.3 million).

CONCLUSIONS

Our results show that SSB taxation may substantially improve oral health and reduce the caries-related economic burden. Benefits would be the greatest for younger age groups.

Characteristics Associated with Household Purchases of Sugar-Sweetened Beverages in US Restaurants

OBJECTIVE

This study aimed to describe beverages purchased in restaurants among a nationally representative sample of US households.

METHODS

Data were obtained from the US Department of Agriculture National Household Food Acquisition and Purchase Survey, 2012 to 2013. Survey-weighted multiple regressions assessed correlates of purchasing a sugar-sweetened beverage (SSB), purchasing a low-calorie beverage, and per capita beverage calories and grams of sugar among purchases from US restaurants (n = 14,669).

RESULTS

Dining at a top fast-food chain (odds ratio = 1.9 [95% CI = 1.6, 2.3] vs. small chain or independent restaurants) and ordering a combination meal (2.8 [1.3, 3.3]) or from the kids' menu (2.1 [1.2, 3.4]) were positively associated with purchasing an SSB. Age (young adult and adolescent vs. older adult; 0.7 [0.5, 0.9] and 0.4 [0.3, 0.7], respectively), race (Black vs. White; 0.4 [0.3, 0.6]), ethnicity (Hispanic vs. non-Hispanic; 0.8 [0.6, 0.9]), and household food security (very low vs. high; 0.7 [0.5, 0.8]) were associated with purchasing a low-calorie beverage. Caloric beverage purchases contained the most calories and grams of sugar per capita when purchased by Hispanic and non-Hispanic Black adolescents.

CONCLUSIONS

US households purchase a considerable amount of SSBs from the nation's largest chain restaurants, particularly when combination meals or kids' menu items are ordered, and there are disparities by age, race/ethnicity, and household food security.

Child and parent perspectives on healthier side dishes and beverages in restaurant kids' meals: results from a national survey in the United States

BACKGROUND

Children frequently consume foods from restaurants; considering the quick-service sector alone, 1/3 of children eat food from these restaurants on a given day, and among these consumers, 1/3 of their daily calories come from fast food. Restaurant foods and beverages are second only to grocery store foods and beverages in their contribution to total energy intake of U.S. 4- to 11-year-olds. Shifting their restaurant consumption in healthier directions could have a positive impact on child health. In 2014 this study examined self-reported child receptivity and parent awareness of child receptivity to ordering a fruit or vegetable side dish instead of French fries; and milk, water, or flavored water instead of soda/pop with a kids' meal when eating out. Child receptivity to side dishes was compared between 2010 and 2014.

METHODS

An online survey was administered by Nielsen via their Harris Poll Online to a national panel of 711 parents and their 8- to 12-year-old child, as part of a larger study. Frequencies, logistic regressions, t-tests, chi-square tests, and percent agreement were used to evaluate child likelihood of ordering certain side dishes; receptivity to healthier side dish and beverage alternatives; changes in receptivity to healthier sides across years; and parent awareness.

RESULTS

A majority of children said they were likely to order a meal with a vegetable (60%), fruit (78%), or French fry (93%) side dish. They were receptive to receiving a fruit or vegetable (FV) side dish instead of French fries (68%); or milk, water, or flavored water instead of soda (81%) with their restaurant kids' meal. Liking/taste was the most common reason for children's feelings. Child receptivity to a FV side dish instead of French fries was high in both years and significantly higher in 2014 (t = -2.12, p = 0.034). The majority of parent and child reports of child receptivity were concordant (85%).

CONCLUSIONS

These national survey results indicate that children are receptive to FV side dishes and healthier beverage options with their restaurant meals. Their receptivity has remained high in the recent past, and parents are aware of child receptivity. An opportunity exists for restaurants to leverage child receptivity to healthier sides and beverages by providing and promoting healthy options.

Progress Evaluation for the Restaurant Industry Assessed by a Voluntary Marketing-Mix and Choice-Architecture Framework That Offers Strategies to Nudge American Customers toward Healthy Food Environments, 2006-2017

Consumption of restaurant food and beverage products high in fat, sugar and sodium contribute to obesity and non-communicable diseases. We evaluated restaurant-sector progress to promote healthy food environments for Americans. We conducted a desk review of seven electronic databases (January 2006-January 2017) to examine restaurant strategies used to promote healthful options in the United States (U.S.). Evidence selection (n = 84) was guided by the LEAD principles (i.e., locate, evaluate, and assemble evidence to inform decisions) and verified by data and investigator triangulation. A marketing-mix and choice-architecture framework was used to examine eight voluntary strategies (i.e., place, profile, portion, pricing, promotion, healthy default picks, priming or prompting and proximity) to evaluate progress (i.e., no, limited, some or extensive) toward 12 performance metrics based on available published evidence. The U.S. restaurant sector has made limited progress to use pricing, profile (reformulation), healthy default picks (choices), promotion (responsible marketing) and priming and prompting (information and labeling); and some progress to reduce portions. No evidence was available to assess progress for place (ambience) and proximity (positioning) to promote healthy choices during the 10-year review period. Chain and non-chain restaurants can apply comprehensive marketing-mix and nudge strategies to promote healthy food environments for customers.