A review of the literature on policies directed at the youth consumption of sugar sweetened beverages

Sugar-Sweetened Beverages Consumption in a Multi-Ethnic Population of Young Men and Association with Sociodemographic Characteristics and Obesity

Sugar-sweetened beverages are frequently consumed among adults and are linked with the incidence of obesity. We aimed to determine rates of weekly and daily sugar-sweetened beverage intake in a multi-ethnic population of young men and their association with sociodemographic characteristics and obesity. This cross-sectional study included 3600 young men who lived in Riyadh, KSA. Participants' sociodemographic characteristics and frequency of sugar-sweetened beverage consumption were gathered through personal interviews. The outcome variables in this study are based on the weekly and daily consumption of sugar-sweetened beverages. Weight and height were measured following standard protocols. The rates of weekly and daily sugar-sweetened beverage intake by participants were 93.6% and 40.8%, respectively. Nationality was a predictor of weekly and daily consumption of sugar-sweetened beverages. The highest rates of weekly (99.5%) and daily (63.9%) consumption were observed in subjects from the Philippines and Yemen, respectively, while Bangladeshi subjects had the lowest rates of weekly (76.9%) and daily (6.9%) consumption. Obesity was another predictor of sugar-sweetened beverage consumption. Obese participants had a significantly higher odds ratio of weekly sugar-sweetened beverage consumption than non-obese subjects (OR = 4.53, p = 0.037). In conclusion, sugar-sweetened beverage consumption was relatively high and our results support an association between the consumption of sugar-sweetened beverages and certain sociodemographic variables and obesity.

Sugar-sweetened beverages consumption in a multi-ethnic population of middle-aged men and association with sociodemographic variables and obesity

Background

Adults frequently consume sugar-sweetened beverages. These products are linked to negative health effects such as obesity. Our study was carried out to assess rates of weekly and daily sugar-sweetened beverages consumption in a multi-ethnic population of middle-aged men and association with sociodemographic variables and obesity.

Methods

A sum of 1,800 middle-aged men (36–59 years) living in Riyadh, KSA, participated in this cross-sectional study. Sociodemographic variables and the frequency of sugar-sweetened beverages consumption were gathered from participants using face to face interviews. Weekly and daily consumption of sugar-sweetened beverages were the two binary outcome variables applied in this research. Weight and height were measured following standard procedures.

Results

In this study, 93.8 and 32.6% of participants consumed sugar-sweetened beverages weekly and daily, respectively. The weekly and daily sugar-sweetened beverages consumption was predicted by nationality. Subjects from Pakistan (99.3%) and Yemen (60.0%) reported the greatest rates of weekly and daily consumption, respectively, while Bangladeshi and Sudanese subjects reported the lowest rates of weekly (87%) and daily (2.9%) consumption, respectively. Another factor that predicted weekly sugar-sweetened beverages consumption was obesity. Obese subjects had a significantly greater odds ratio of weekly sugar-sweetened beverages intake than non-obese individuals (OR = 3.80, P = 0.003).

Conclusion

Consumption of sugar-sweetened beverages is common among middle-aged men who live in KSA. Results show connecting sugar-sweetened beverages intake with specific sociodemographic variables and obesity.

The effect of unhealthy dietary habits on the incidence of dental caries and overweight/obesity among Egyptian school children (A cross-sectional study)

Background

Obesity and dental caries are public health problems in Egypt. Factors such as unhealthy diet, poor oral hygiene, and physical inactivity can play a major role in both problems. This study was carried out to illuminate the mutual unhealthy dietary risk factors associated with the incidence of both health conditions.

Methods

Between 1 October 2020 and 1 July 2021, 369 Egyptian children (5-10 years) were examined. Dental status was assessed using decayed, missing/extracted, and filled tooth indices (dmft, deft, and DMFT) for deciduous, mixed, and permanent dentitions, respectively. Moreover, the lifestyle, food habits, and body mass index (BMI) were recorded.

Results

A total of 342 (93.7%) of the included subjects suffered from caries, and only 27(7.3%) were caries-free. Based on BMI percentiles, 247 (66.9%) of the youngsters were overweight/obese, while 122 (33.1%) had normal weight. The mean dmft was 6.9 (±4.6), deft 4.2 (±3.3), and DMFT 0.1 (±1.7). In the primary dentition, a significant positive correlation was detected between dmft and BMI, legumes, sweetened milk and juice, soft drinks, and desserts, while a significant negative correlation was detected between dmft/deft, meat/poultry/fish, fresh fruits, and vegetables. A significant positive correlation was detected between deft and BMI, sweetened milk and juice, ice cream, candies, and crackers. In the permanent dentition, a significant positive correlation was detected between age, soft drinks, sweetened juice, desserts, and DMFT, while a significant negative correlation was detected with fresh fruits and vegetables. BMI was significantly negatively correlated with a healthy lifestyle, meat/poultry/fish consumption, and fresh fruits and vegetables while positively correlated with legumes, ice cream, soft drinks, granulated sugars, desserts, fast food, and caffeinated drinks.

Conclusion

Overweight/obesity was positively correlated with primary dentition dental caries. Desserts (sweetened snacks) and soft drinks could be the common risk factors associated with high caries and overweight/obesity incidence among Egyptian school children; conversely, consumption of fruits and vegetables could hinder both health conditions. Moreover, sweetened juices were associated with primary and permanent dental caries.

Fructose Intake, Hypertension and Cardiometabolic Risk Factors in Children and Adolescents: From Pathophysiology to Clinical Aspects. A Narrative Review

Arterial hypertension, dyslipidemia, alterations in glucose metabolism and fatty liver, either alone or in association, are frequently observed in obese children and may seriously jeopardize their health. For obesity to develop, an excessive intake of energy-bearing macronutrients is required; however, ample evidence suggests that fructose may promote the development of obesity and/or metabolic alterations, independently of its energy intake. Fructose consumption is particularly high among children, because they do not have the perception, and more importantly, neither do their parents, that high fructose intake is potentially dangerous. In fact, while this sugar is erroneously viewed favorably as a natural nutrient, its excessive intake can actually cause adverse cardio-metabolic alterations. Fructose induces the release of pro-inflammatory cytokines, and reduces the production of anti-atherosclerotic cytokines, such as adiponectin. Furthermore, by interacting with hunger and satiety control systems, particularly by inducing leptin resistance, it leads to increased caloric intake. Fructose, directly or through its metabolites, promotes the development of obesity, arterial hypertension, dyslipidemia, glucose intolerance and fatty liver. This review aims to highlight the mechanisms by which the early and excessive consumption of fructose may contribute to the development of a variety of cardiometabolic risk factors in children, thus representing a potential danger to their health. It will also describe the main clinical trials performed in children and adolescents that have evaluated the clinical effects of excessive intake of fructose-containing drinks and food, with particular attention to the effects on blood pressure. Finally, we will discuss the effectiveness of measures that can be taken to reduce the intake of this sugar.

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.

Dietary Intake and Sources of Added Sugars in Various Food Environments in Costa Rican Adolescents

Consumption of added sugars, especially from sugar-sweetened beverages (SSBs), has been associated with several negative health outcomes during adolescence. This study aimed to identify dietary intake and food sources of added sugars in the home, school, and neighborhood environments of Costa Rican adolescents. Dietary intake of added sugars was determined using 3-day food records in a cross-sectional study of 818 adolescents aged 12 to 19 and enrolled in rural and urban schools in the province of San José. On average, 90% of adolescents consumed more than 10% of their total energy intake from added sugars. Furthermore, 74.0% of added sugars were provided at home, 17.4% at school, and 8.6% in the neighborhood. Added sugars were primarily provided by frescos (29.4%), fruit-flavored still drinks (22.9%), and sugar-sweetened carbonated beverages (12.3%), for a total contribution of 64.6%. Our findings suggest that Costa Rican adolescents have a plethora of added sugar sources in all food environments where they socialize. However, it is relevant for public health to consider the home and school environments as fundamental units of interventions aimed at reducing added sugars in the adolescent diet. Frescos prepared at home and school and fruit-flavored still drinks must be the focus of these interventions.

Impact of Measures Aiming to Reduce Sugars Intake in the General Population and Their Implementation in Europe: A Scoping Review

Objectives: Implementing public health measures is necessary to decrease sugars intake, which is associated with increased risk of noncommunicable diseases. Our scoping review aimed to identify the types of measures implemented and evaluated to decrease sugars intake in the population and to assess their impact.

Methods: Following a review of systematic reviews (SRs) published in 2018, we systematically searched new SR (May 2017–October 2020) in electronic databases. We also searched the measures implemented in Europe in the NOURISHING database. Two researchers selected the reviews, extracted and analysed the data.

Results: We included 15 SRs assessing economic tools (n = 5), product reformulation and labels/claims (n = 5), and educational/environmental interventions (n = 7). Economic tools, product reformulation and environmental measures were effective to reduce sugar intake or weight outcomes, while labels, education and interventions combining educational and environmental measures found mixed effects. The most frequently implemented measures in Europe were public awareness, nutritional education, and labels.

Conclusion: Among measures to reduce sugar intake in the population, economic tools, product reformulation, and environmental interventions were the most effective, but not the more frequently implemented in Europe.

Gamification and Sugar: A School-Based Pilot Study of Social Marketing and Gamification Approaches to Reduce Sugary Drink Intake in Pasifika School Students

The aim of this study was to investigate a social marketing-gamification intervention to reduce sugary drink intake drawing on popular culture of Pasifika secondary school students in Auckland, New Zealand. Students aged 11 to 14 years from one coeducational high school participated in the 11-week pilot study. The 9-week intervention was undertaken in assemblies and classrooms. Baseline and follow-up measures were completed by 227 and 220 students, respectively, of 298 enrolled students. Retention of the "3-6-9" teaching related to maximum daily sugar intake increased from 9% at baseline to 97% at follow-up (P < .0001). Significant increases were observed of students who correctly answered sugar content of drinks. Overall consumption of sugary drink decreased at follow-up by 0.46 glasses per day. The main conclusion from this study was that this school-based gamification educational package to convey messages about sugar content of drinks using popular modes of engagement is a promising intervention that was acceptable and well supported by school staff and students.

The drivers, trends and dietary impacts of non-nutritive sweeteners in the food supply: a narrative review

Poor diets, including excess added sugar consumption, contribute to the global burden of disease. Subsequently, many nutrition policies have been implemented to reduce added sugar intake and improve population health, including taxes, education, labelling and environmental interventions. A potential consequence of these policy actions is the substitution of added sugars with non-nutritive sweeteners (NNS) in a variety of foods and beverages. NNS are used to reduce the energy and sugar content of foods and beverages while maintaining their palatability. Evidence of the toxicological risks of NNS is inconsistent, though concerns have been raised over the potential substitution effects of ultra-processed foods containing NNS for whole foods. This review aimed to provide an overview of current NNS food supply and consumption patterns, assess added sugar-reduction policies and their impact on NNS, and determine the impact of NNS on food choice, energy intake and diet quality. NNS are widely available in a variety of products, though most commonly in carbonated beverages, dairy products, confectionery, table-top sweeteners and fruit drinks. However, the longitudinal trends of different product categories, and differences between geographies and economy-income levels, require further study. Few studies have examined NNS consumption trends globally, though an increase in NNS consumption in beverages has been observed in some regions. Research examining how the increased availability of low-sugar, NNS-containing products affects global dietary patterns is limited, particularly in terms of their potential substitution effects.

School-Based Intervention to Improve Healthy Eating Practices Among Malaysian Adolescents: A Feasibility Study Protocol

Introduction: School environments can influence students' dietary habits. Hence, implementing a healthy canteen intervention programme in schools is a recommended strategy to improve students' dietary intake. This study will evaluate the feasibility of providing healthier food and beverage options in selected secondary schools in Malaysia by working with canteen vendors. It also will assess the changes in food choices before and after the intervention.

Methods: A feasibility cluster randomised controlled study will be conducted in six secondary schools (intervention, n = 4; control, n = 2) comprising of rural and urban schools located in Selangor and Perak states in Malaysia. Four weeks of intervention will be conducted among Malaysian adolescents aged 15 years old. Two interventions are proposed that will focus on providing healthier food options in the canteen and convenience shops in the selected schools. Interventions 1 and 2 will entail training the canteen and school convenience shop operators. Intervention 2 will be applied to subsidise the cost of low energy-dense kuih (traditional cake), vegetables, and fruits. The control group will continue to sell the usual food. Trained dietitians will audit the canteen menu and food items sold by the school canteen and convenience shops in all schools. Anthropometric measurements, blood pressure and dietary assessment will be collected at baseline and at the end of 4-week intervention. Focus group discussions with students and in-depth interviews with headmasters, teachers, and school canteen operators will be conducted post-intervention to explore intervention acceptability. Under this Healthy School Canteen programme, school canteens will be prohibited from selling “red flag” foods. This refers to foods which are energy-dense and not nutritious, such as confectionery and deep-fried foods. They will also be prohibited from selling soft drinks, which are sugar-rich. Instead, the canteens will be encouraged to sell “green flag” food and drinks, such as fruits and vegetables.

Conclusion: It is anticipated that this feasibility study can provide a framework for the conception and implementation of nutritional interventions in a future definitive trial at the school canteens in Malaysia.

Distributional Changes in U.S. Sugar-Sweetened Beverage Purchases, 2002-2014

INTRODUCTION

U.S. policy actions focus on reducing sugar-sweetened beverage purchases. Yet, there are no studies on trends in overall purchase distribution and how it has changed by key subpopulations. This study examined changes in distributions of total sugar-sweetened beverage purchases and its major subtypes (regular carbonated soft drinks and fruit/sports/energy drinks) in 2002-2014 and distinguished among low, moderate, and high purchasers.

METHODS

Longitudinal data on sugar-sweetened beverage purchases of U.S. households from the 2002-2014 Nielsen Homescan Panel were used. Sugar-sweetened beverages were defined as all caloric non-alcoholic beverages containing added sugars. Longitudinal quantile regression model examined trends across distributions (from quantile 25 to 95) of purchases (measured in kcal/day/capita), while accounting for households' unobserved differences. All statistical analyses were conducted in 2019.

RESULTS

All households across the total purchase distribution significantly reduced their purchases. High purchasers made less proportional reductions than low purchasers (e.g., 35% at 95th quantile vs 62% at 25th quantile). However, the smaller relative reductions among higher purchasers translated into larger absolute decreases (e.g., 134 kcal/day/capita at 95th quantile vs 23 kcal/day/capita at 25th quantile). Similar patterns in heterogeneity were observed across sugar-sweetened beverage subtype distributions and among racial/ethnic and income groups. In addition, there were significant racial/ethnic and income disparities in total sugar-sweetened beverage purchases in 2002-2003. Although racial/ethnic disparities among higher purchasers improved, income disparity patterns at all purchase levels persisted into 2013-2014.

CONCLUSIONS

From 2002‒2003 to 2013-2014, U.S. households at all purchase levels made meaningful reductions in sugar-sweetened beverage purchases in both absolute and relative terms. Furthermore, racial/ethnic disparities in total sugar-sweetened beverage purchases narrowed, but income disparity patterns persisted.

Determining predictors of change in sugar sweetened beverage consumption behaviour among university students in India

Background Consumption of sugar sweetened beverages (SSBs) is a significant risk behaviour that leads to the development of several chronic diseases. The present study aimed to predict the SSB consumption behaviour among Indian university students by utilising a multi theory model (MTM) of health behaviour change. Methods In a cross-sectional design, a validated 37-item self-report questionnaire was administered to 267 participants from a mid-size university in the National Capital Region (NCR) of India. Stepwise multiple regressions were used to determine predictors of change in initiation and sustenance of SSB consumption behaviour. For stepwise multiple regression, the a priori criteria of probability of F to enter the predictor in the model was set as less than or equal to 0.05 and for removing the predictor as greater than or equal to 0.10. Results The model was able to predict 16.7% variance in behavioural initiation through the constructs of participatory dialogue and behavioural confidence, and 30.2% variance in sustenance through emotional transformation and change in social environment. Participatory dialogue and behavioural confidence were predictors of behaviour initiation; and emotional transformation, and change in social environment were predictors of behaviour sustenance for SSB consumption behaviour change. Conclusion The study provided a pathway for design of interventions for SSB intake reduction in Indian university students. Interventions should be designed using participatory dialogue and behavioural confidence initiation, and emotional transformation and change in social environment for sustenance of change in SSB consumption in this population.

Effectiveness of behavioral interventions to reduce the intake of sugar-sweetened beverages in children and adolescents: a systematic review and meta-analysis

Context

Consumption of sugar-sweetened beverages (SSBs) among children has been associated with adverse health outcomes. Numerous behavioral interventions aimed at reducing the intake of SSBs among children have been reported, yet evidence of their effectiveness is lacking.

Objective

This systematic review explored the effectiveness of educational and behavioral interventions to reduce SSB intake and to influence health outcomes among children aged 4 to 16 years.

Data Sources

Seven databases were searched for randomized controlled trials published prior to September 2016. Studies identified were screened for eligibility.

Study Selection

Trials were included in the review if they met the PICOS (Population, Intervention, Comparison, Outcome, and Study design) criteria for inclusion of studies.

Data Extraction

Data were extracted by 2 reviewers following Cochrane guidelines and using Review Manager software.

Results

Of the 16 trials included, 12 were school based and 4 were community or home based. Only 3 trials provided data that could be pooled into a meta-analysis for evaluating change in SSB intake. Subgroup analyses showed a trend toward a significant reduction in SSB intake in participants in school-based interventions compared with control groups. Change in body mass index z scores was not statistically significant between groups.

Conclusions

The quality of evidence from included trials was considered moderate, and the effectiveness of educational and behavioral interventions in reducing SSB intake was modest.

Systematic Review Registration

PROSPERO registration number CRD42014004432.

Kids SIPsmartER, a cluster randomized controlled trial and multi-level intervention to improve sugar-sweetened beverages behaviors among Appalachian middle-school students: Rationale, design & methods

The intake of sugar-sweetened beverages (SSB) is disproportionately high in Appalachia, including among adolescents whose intake is more than double the national average and more than four times the recommended daily amount. Unfortunately, there is insufficient evidence for effective strategies targeting SSB behaviors among Appalachian youth in real-world settings, including rural schools. Kids SIPsmartER is a 6-month, school-based, behavior and health literacy program aimed at improving SSB behaviors among middle school students. The program also integrates a two-way short message service (SMS) strategy to engage caregivers in SSB role modeling and supporting home SSB environment changes. Kids SIPsmartER is grounded by the Theory of Planned Behavior and health literacy, media literacy, numeracy, and public health literacy concepts. Guided by the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance), this type 1 hybrid design and cluster randomized controlled trial targets 12 Appalachian middle schools in southwest Virginia. The primary aim evaluates changes in SSB behaviors at 7-months among 7th grade students at schools receiving Kids SIPsmartER, as compared to control schools. Secondary outcomes include other changes in students (e.g., BMI, quality of life, theory-related variables) and caregivers (e.g., SSB behaviors, home SSB environment), and 19-month maintenance of these outcomes. Reach is assessed, along with mixed-methods strategies (e.g., interviews, surveys, observation) to determine how teachers implement Kids SIPsmartER and the potential for institutionalization within schools. This paper discusses the rationale for implementing and evaluating a type 1 hybrid design and multi-level intervention addressing pervasive SSB behaviors in Appalachia. Clincialtrials.gov: NCT03740113.

Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

BACKGROUND

Frequent consumption of excess amounts of sugar-sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.

OBJECTIVES

To assess the effects of environmental interventions (excluding taxation) on the consumption of sugar-sweetened beverages and sugar-sweetened milk, diet-related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.

SEARCH METHODS

We searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.

SELECTION CRITERIA

We included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet-related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after (CBA) and interrupted-time-series (ITS) studies, implemented in real-world settings with a combined length of intervention and follow-up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB-specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta-analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented 'Summary of findings' tables.

MAIN RESULTS

We identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow-up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non-randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate-certainty evidence that traffic-light labelling is associated with decreasing sales of SSBs, and low-certainty evidence that nutritional rating score labelling is associated with decreasing sales of SSBs. For menu-board calorie labelling reported effects on SSB sales varied.Nutrition standards in public institutions (16 studies): We found low-certainty evidence that reduced availability of SSBs in schools is associated with decreased SSB consumption. We found very low-certainty evidence that improved availability of drinking water in schools and school fruit programmes are associated with decreased SSB consumption. Reported associations between improved availability of drinking water in schools and student body weight varied.Economic tools (7 studies): We found moderate-certainty evidence that price increases on SSBs are associated with decreasing SSB sales. For price discounts on low-calorie beverages reported effects on SSB sales varied.Whole food supply interventions (3 studies): Reported associations between voluntary industry initiatives to improve the whole food supply and SSB sales varied.Retail and food service interventions (7 studies): We found low-certainty evidence that healthier default beverages in children's menus in chain restaurants are associated with decreasing SSB sales, and moderate-certainty evidence that in-store promotion of healthier beverages in supermarkets is associated with decreasing SSB sales. We found very low-certainty evidence that urban planning restrictions on new fast-food restaurants and restrictions on the number of stores selling SSBs in remote communities are associated with decreasing SSB sales. Reported associations between promotion of healthier beverages in vending machines and SSB intake or sales varied.Intersectoral approaches (8 studies): We found moderate-certainty evidence that government food benefit programmes with restrictions on purchasing SSBs are associated with decreased SSB intake. For unrestricted food benefit programmes reported effects varied. We found moderate-certainty evidence that multicomponent community campaigns focused on SSBs are associated with decreasing SSB sales. Reported associations between trade and investment liberalisation and SSB sales varied.Home-based interventions (7 studies): We found moderate-certainty evidence that improved availability of low-calorie beverages in the home environment is associated with decreased SSB intake, and high-certainty evidence that it is associated with decreased body weight among adolescents with overweight or obesity and a high baseline consumption of SSBs.Adverse outcomes reported by studies, which may occur in some circumstances, included negative effects on revenue, compensatory SSB consumption outside school when the availability of SSBs in schools is reduced, reduced milk intake, stakeholder discontent, and increased total energy content of grocery purchases with price discounts on low-calorie beverages, among others. The certainty of evidence on adverse outcomes was low to very low for most outcomes.We analysed interventions targeting sugar-sweetened milk separately, and found low- to moderate-certainty evidence that emoticon labelling and small prizes for the selection of healthier beverages in elementary school cafeterias are associated with decreased consumption of sugar-sweetened milk. We found low-certainty evidence that improved placement of plain milk in school cafeterias is not associated with decreasing sugar-sweetened milk consumption.

AUTHORS' CONCLUSIONS

The evidence included in this review indicates that effective, scalable interventions addressing SSB consumption at a population level exist. Implementation should be accompanied by high-quality evaluations using appropriate study designs, with a particular focus on the long-term effects of approaches suitable for large-scale implementation.

Sugar-Sweetened Beverages Contribute Significantly to College Students' Daily Caloric Intake in Jordan: Soft Drinks Are Not the Major Contributor

Sugar sweetened beverages (SSBs) are caloric-dense and associated with poor diet quality which may result in weight gain and obesity. Obesity is an independent risk factor for several chronic diseases. This study aimed to (1) assess the consumption level of SSBs among college students in Jordan and (2) examine the relationship of consumption level to body weight. The current study is a cross-sectional study conducted on 967 college students (55.3% males and 44.7% females). Consumption of SSBs was assessed using validated questionnaires. SSBs were classified into four major categories (hot drinks, fruit drinks, energy drinks, and soft drinks). Anthropometric measurements of the participants including body weight, height, and waist circumferences were recorded. Male students consumed more calories from SSBs compared to female students (p = 0.016). The mean contribution of SSBs to daily energy intake among college students was 480 kcal with the highest contribution from sugar sweetened hot drinks and fruit drinks. A significant positive relationship was found in BMI (p = 0.006) and waist circumference (p = 0.030) for participants consuming calories from SSBs. In conclusion, beverages with added sugar contribute substantially to the daily energy intake of college students in Jordan.

A qualitative exploration of parents', youths' and food establishment managers' perceptions of beverage industry self-regulation for obesity prevention

OBJECTIVE

We aimed to explore the range of stakeholders' perceptions of the Balance Calories Initiative (BCI), under which the American Beverage Association pledged to decrease per capita US consumption of beverage energy by 20 % by 2025.

DESIGN

Semi-structured cross-sectional interviews were conducted in 2017.

SETTING

Participants were recruited from communities targeted by the BCI (Montgomery, AL; North Mississippi Delta, MS; Eastern Los Angeles, CA).ParticipantsA total of thirty-three parents and thirty-eight youths aged 10-17 years were recruited through youth-serving organizations, street intercept and snowball sampling; sixteen store/restaurant managers were recruited at businesses. Participants were asked about their awareness of the BCI. Parents and youths were asked to 'think aloud' as they viewed BCI messages (e.g. 'Balance What You Eat, Drink, and Do') and managers were asked about beverage marketing.

RESULTS

Twelve parents and twenty-four youths had seen BCI messages; only four managers were aware of the BCI. Many parents and youths showed some misunderstanding of BCI messages (e.g. that they should drink more sugar-sweetened beverages (SSB) or they needed to equalize healthy and unhealthy beverage intake). Only one manager had communicated with beverage companies about the BCI.

CONCLUSIONS

We found mixed comprehension and low awareness of BCI messages in communities targeted by the American Beverage Association for reduced SSB consumption. Industry self-regulation attempts to reduce SSB consumption may have limited effectiveness if stakeholder input is not addressed. Public health practitioners should be aware of the need to address youths' and parents' misunderstandings about SSB consumption, especially in BCI-targeted communities.

Persistent disparities over time in the distribution of sugar-sweetened beverage intake among children in the United States

Background

Recent research suggests that sugar-sweetened beverage (SSB) consumption has been declining among US children aged 2-18 y. However, most studies focused on changes in mean intake, ignore high SSB consumers and do not examine intake among vulnerable groups and, including adolescents, low-income households, and several racial/ethnic minorities.

Objective

The aim was to estimate usual SSB intake from NHANES surveys from 2003-2004 to 2013-2014 to examine shifts at both the median and 90th percentile among US children, evaluating the extent to which intake disparities in total SSBs and subtypes have persisted.

Design

Children 2-18 y from NHANES 2003, 2005, 2007, 2009, 2011 and 2013. SSBs were all non-diet beverages sweetened with sugars including revising all beverages to as consumed status and excluding soy and dairy based beverages. The NCI usual intake method was used to estimate usual intake from two 24-hour recalls. A 2-part correlated model accounted for nonconsumers. Quantile regression was then used to examine differences in SSB usual intakes at the 50th and 90th percentiles by race-ethnicity, and examine interactions indicating whether racial-ethnic disparities in intake were modified by income.

Results

Despite considerable declines, children's SSB intake remains high, particularly among heavy consumers. Among adolescents, median SSB intake in 2013-2014 was on the order of 150-200 kcal/d, and heavy intake at the 90th percentile was on the order of 250-300 kcal/d. There were important disparities in intake that persisted over time. Although high household income was associated with lower SSB intake in non-Hispanic white (NHW) children, intakes of non-Hispanic black (NHB) and Mexican-American (MA) children from these households were similar to or higher than those from poor households. There were also large racial/ethnic differences in the types of SSBs consumed. The consumption of regular sodas by NHB children was somewhat lower than among MA and NHW children, whereas fruit drink intake was markedly higher.

Conclusions

Overall, these findings suggest that, despite recent declines, strategies are needed to further reduce SSB consumption, and particularly heavy intake, especially among NHB children where fruit drinks also are key source of SSBs.

Examining changes in school vending machine beverage availability and sugar-sweetened beverage intake among Canadian adolescents participating in the COMPASS study: a longitudinal assessment of provincial school nutrition policy compliance and effectiveness

Background

School nutrition policies can encourage restrictions in sugar-sweetened beverage (SSB) availability in school food outlets in order to discourage students’ SSB intake. The main objective was to examine how beverage availability in school vending machines changes over three school years across schools in distinct school nutrition policy contexts. Secondary objectives were to examine how students’ weekday SSB intake varies with time and identify longitudinal associations between beverage availability and SSB intake.

Methods

This longitudinal study used data from the COMPASS study (2013/14–2015/16), representing 7679 students from 78 Canadian secondary schools and three provincial school nutrition policy contexts (Alberta – voluntary guidelines, Ontario public – mandatory guidelines, and Ontario private schools – no guidelines). We assessed availability of 10 beverage categories in schools’ vending machines via the COMPASS School Environment Application and participants’ intake of three SSB varieties (soft drinks, sweetened coffees/teas, and energy drinks) via a questionnaire. Hierarchical regression models were used to examine whether: i) progression of time and policy group were associated with beverage availability; and, ii) beverage availability was associated with students’ SSB intake.

Results

Ontario public schools were significantly less likely than the other policy groups to serve SSBs in their vending machines, with the exception of flavoured milks. Vending machine beverage availability was consistent over time. Participants’ overall SSB intake remained relatively stable; reductions in soft drink intake were partially offset by increased sweetened coffee/tea consumption. Relative to Ontario public schools, attending school in Alberta was associated with more frequent energy drink intake and overall SSB intake whereas attending an Ontario private school was associated with less frequent soft drink intake, with no differences in overall SSB intake. Few beverage availability variables were significantly associated with participants’ SSB intake.

Conclusions

Mandatory provincial school nutrition policies were predictive of more limited SSB availability in school vending machines. SSB intake was significantly lower in Ontario public and private schools, although we did not detect a direct association between SSB consumption and availability. The findings provide support for mandatory school nutrition policies, as well as the need for comprehensive school- and broader population-level efforts to reduce SSB intake.

Electronic supplementary material

The online version of this article (10.1186/s12966-018-0754-5) contains supplementary material, which is available to authorized users.

Gaps in the Evidence on Population Interventions to Reduce Consumption of Sugars: A Review of Reviews

There is currently considerable attention directed to identifying promising interventions to reduce consumption of sugars among populations around the world. A review of systematic reviews was conducted to identify gaps in the evidence on such interventions. Medline, EMBASE CINAHL, and the Cochrane Database of Systematic Reviews were searched to identify systematic reviews published in English from January 2005 to May 2017 and considering research on interventions to reduce sugar intake. Twelve systematic reviews that considered price changes, interventions to alter the food available within specific environments, and health promotion and education programs were examined. Each of the identified reviews focused on sugar-sweetened beverages (SSBs). The existing literature provides some promising indications in terms of the potential of interventions to reduce SSB consumption among populations. However, a common thread is the limited scope of available evidence, combined with the heterogeneity of methods and measures used in existing studies, which limits conclusions that can be reached regarding the effectiveness of interventions. Reviewed studies typically had limited follow-up periods, making it difficult to assess the sustainability of effects. Further, there is a lack of studies that address the complex context within which interventions are implemented and evaluated, and little is known about the cost-effectiveness of interventions. Identified gaps speak to the need for a more holistic approach to sources of sugars beyond SSBs, consensus on measures and methods, attention to the implementation of interventions in relation to context, and careful monitoring to identify intended and unintended consequences.

Comparative risk assessment of school food environment policies and childhood diets, childhood obesity, and future cardiometabolic mortality in the United States

BACKGROUND

Promising school policies to improve children's diets include providing fresh fruits and vegetables (F&V) and competitive food restrictions on sugar-sweetened beverages (SSBs), yet the impact of national implementation of these policies in US schools on cardiometabolic disease (CMD) risk factors and outcomes is not known. Our objective was to estimate the impact of national implementation of F&V provision and SSB restriction in US elementary, middle, and high schools on dietary intake and body mass index (BMI) in children and future CMD mortality.

METHODS

We used comparative risk assessment (CRA) frameworks to model the impacts of these policies with input parameters from nationally representative surveys, randomized-controlled trials, and systematic reviews and meta-analyses. For children ages 5-18 years, this incorporated national data on current dietary intakes and BMI, impacts of these policies on diet, and estimated effects of dietary changes on BMI. In adults ages 25 and older, we further incorporated the sustainability of dietary changes to adulthood, effects of dietary changes on CMD, and national CMD death statistics, modeling effects if these policies had been in place when current US adults were children. Uncertainty across inputs was incorporated using 1000 Monte Carlo simulations.

RESULTS

National F&V provision would increase daily fruit intake in children by as much as 25.0% (95% uncertainty interval (UI): 15.4, 37.7%), and would have small effects on vegetable intake. SSB restriction would decrease daily SSB intake by as much as 26.5% (95% UI: 6.4, 46.4%), and reduce BMI by as much as 0.7% (95% UI: 0.2, 1.2%). If F&V provision and SSB restriction were nationally implemented, an estimated 22,383 CMD deaths/year (95% UI: 18735, 25930) would be averted.

CONCLUSION

National school F&V provision and SSB restriction policies implemented in elementary, middle, and high schools could improve diet and BMI in children and reduce CMD mortality later in life.

Kids SIP smartER: A Feasibility Study to Reduce Sugar-Sweetened Beverage Consumption Among Middle School Youth in Central Appalachia

PURPOSE

To test the feasibility of Kids SIP smartER, a school-based intervention to reduce consumption of sugar-sweetened beverages (SSBs).

DESIGN

Matched-contact randomized crossover study with mixed-methods analysis.

SETTING

One middle school in rural, Appalachian Virginia.

PARTICIPANTS

Seventy-four sixth and seventh graders (5 classrooms) received Kids SIP smartER in random order over 2 intervention periods. Feasibility outcomes were assessed among 2 teachers.

INTERVENTION

Kids SIP smartER consisted of 6 lessons grounded in the Theory of Planned Behavior, media literacy, and public health literacy and aimed to improve individual SSB behaviors and understanding of media literacy and prevalent regional disparities. The matched-contact intervention promoted physical activity.

MEASURES

Beverage Intake Questionnaire-15 (SSB consumption), validated theory questionnaires, feasibility questionnaires (student and teacher), student focus groups, teacher interviews, and process data (eg, attendance).

ANALYSIS

Repeated measures analysis of variances across 3 time points, descriptive statistics, and deductive analysis of qualitative data.

RESULTS

During the first intervention period, students receiving Kids SIP smartER (n = 43) significantly reduced SSBs by 11 ounces/day ( P = .01) and improved media ( P < .001) and public health literacy ( P < .01) understanding; however, only media literacy showed between-group differences ( P < .01). Students and teachers found Kids SIP smartER acceptable, in-demand, practical, and implementable within existing resources.

CONCLUSION

Kids SIP smartER is feasible in an underresourced, rural school setting. Results will inform further development and large-scale testing of Kids SIP smartER to reduce SSBs among rural adolescents.

Hypertension in Children: Role of Obesity, Simple Carbohydrates, and Uric Acid

Over the past 60 years there has been a dramatic increase in the prevalence of overweight in children and adolescents, ranging from 4% in 1975 to 18% in 2016. Recent estimates indicate that overweight or obese children and adolescents are more than 340 million. Obesity is often associated with hypertension, which is an important cardiovascular risk factor. Recent studies show that the presence of hypertension is a frequent finding in the pediatric age. Hypertensive children easily become hypertensive adults. This phenomenon contributes to increasing cardiovascular risk in adulthood. Primary hypertension is a growing problem especially in children and adolescents of western countries, largely because of its association with the ongoing obesity epidemic. Recently, it has been hypothesized that a dietary link between obesity and elevated blood pressure (BP) values could be simple carbohydrate consumption, particularly fructose, both in adults and in children. Excessive intake of fructose leads to increased serum uric acid (SUA) and high SUA values are independently associated with the presence of hypertension and weaken the efficacy of lifestyle modifications in children. The present review intends to provide an update of existing data regarding the relationship between BP, simple carbohydrates (particularly fructose), and uric acid in pediatric age. In addition, we analyze the national policies that have been carried out over the last few years, in order to identify the best practices to limit the socio-economic impact of the effects of excessive sugar consumption in children.

Sugar-Sweetened Beverage, Obesity, and Type 2 Diabetes in Children and Adolescents: Policies, Taxation, and Programs

PURPOSE OF REVIEW

Obesity has grown at an alarming rate in children and adolescents. Concurrently, consumption on sugar-sweetened beverages (SSBs) also rose significantly. This review provides an overview of obesity and type 2 diabetes mellitus (T2DM) related to SSBs and current policies restricting SSBs in schools, school-based interventions, and taxation on reducing SSB intake and obesity. We also discuss challenges of and future steps for these initiatives.

RECENT FINDINGS

Clinical and epidemiological studies suggest a strong association between SSB intake and obesity and T2DM. School food policies have been initiated at federal, state, and local levels. School-based interventions have shown positive effects on SSB intake and obesity reduction. Taxation on SSBs is promising in combating obesity and in generating revenue. Challenges towards compliance and implementation of the policies and programs exist. The relationship between SSB and obesity and T2DM is a complex problem which requires comprehensive solutions. Continued efforts in restricting SSBs in schools are needed. Intervention programs should be tailored to age, gender, language, and culture and involve participation from families and local communities. Taxation can reduce SSB consumption by direct economic incentive, earmarking revenues to support healthy foods, and sending negative message. However, a higher tax rate may be necessary to have a measurable effect on weight.

Effectiveness of school food environment policies on children's dietary behaviors: A systematic review and meta-analysis

Background

School food environment policies may be a critical tool to promote healthy diets in children, yet their effectiveness remains unclear.

Objective

To systematically review and quantify the impact of school food environment policies on dietary habits, adiposity, and metabolic risk in children.

Methods

We systematically searched online databases for randomized or quasi-experimental interventions assessing effects of school food environment policies on children’s dietary habits, adiposity, or metabolic risk factors. Data were extracted independently and in duplicate, and pooled using inverse-variance random-effects meta-analysis. Habitual (within+outside school) dietary intakes were the primary outcome. Heterogeneity was explored using meta-regression and subgroup analysis. Funnel plots, Begg’s and Egger’s test evaluated potential publication bias.

Results

From 6,636 abstracts, 91 interventions (55 in US/Canada, 36 in Europe/New Zealand) were included, on direct provision of healthful foods/beverages (N = 39 studies), competitive food/beverage standards (N = 29), and school meal standards (N = 39) (some interventions assessed multiple policies). Direct provision policies, which largely targeted fruits and vegetables, increased consumption of fruits by 0.27 servings/d (n = 15 estimates (95%CI: 0.17, 0.36)) and combined fruits and vegetables by 0.28 servings/d (n = 16 (0.17, 0.40)); with a slight impact on vegetables (n = 11; 0.04 (0.01, 0.08)), and no effects on total calories (n = 6; -56 kcal/d (-174, 62)). In interventions targeting water, habitual intake was unchanged (n = 3; 0.33 glasses/d (-0.27, 0.93)). Competitive food/beverage standards reduced sugar-sweetened beverage intake by 0.18 servings/d (n = 3 (-0.31, -0.05)); and unhealthy snacks by 0.17 servings/d (n = 2 (-0.22, -0.13)), without effects on total calories (n = 5; -79 kcal/d (-179, 21)). School meal standards (mainly lunch) increased fruit intake (n = 2; 0.76 servings/d (0.37, 1.16)) and reduced total fat (-1.49%energy; n = 6 (-2.42, -0.57)), saturated fat (n = 4; -0.93%energy (-1.15, -0.70)) and sodium (n = 4; -170 mg/d (-242, -98)); but not total calories (n = 8; -38 kcal/d (-137, 62)). In 17 studies evaluating adiposity, significant decreases were generally not identified; few studies assessed metabolic factors (blood lipids/glucose/pressure), with mixed findings. Significant sources of heterogeneity or publication bias were not identified.

Conclusions

Specific school food environment policies can improve targeted dietary behaviors; effects on adiposity and metabolic risk require further investigation. These findings inform ongoing policy discussions and debates on best practices to improve childhood dietary habits and health.

Home Sweet Home: Parent and Home Environmental Factors in Adolescent Consumption of Sugar-Sweetened Beverages

OBJECTIVE

Sugar-sweetened beverages (SSBs) are key contributors to obesity among youth. We investigated associations among parental and home-related factors (parental attitudes and consumption; home availability) regarding 3 types of SSBs-soda, sports drinks, and fruit-flavored drinks-with consumption of each type of SSB in a general school-based sample of adolescents.

METHODS

Data were collected across 3 school semesters, from 2009 to 2011. A total of 1313 seventh grade student-parent dyads participated. Students completed in-class surveys across 9 schools in a large Los Angeles school district; their parents completed telephone interviews. Youth were asked about their SSB consumption (soda, sports drinks, and fruit-flavored drinks), and parents were asked about their attitudes, consumption, and home availability of SSBs.

RESULTS

We estimated expected rates of youth SSB consumption for hypothetical parents at very low (5th) and very high (95th) percentiles for home/parental risk factors (ie, they consumed little, had negative attitudes, and did not keep SSBs in the home; or they consumed a lot, had positive attitudes, and did keep SSBs in the home). Youth of lower-risk parents (at the 5th percentile) were estimated to drink substantially less of each type of beverage than did youth of higher-risk parents (at the 95th percentile). For example, youth with higher-risk parents averaged nearly double the SSB consumption of youth of lower-risk parents (2.77 vs 1.37 glasses on the previous day; overall model significance F_22,1312 = 3.91, P < .001).

CONCLUSIONS

Results suggest a need to focus on parental and home environmental factors when intervening to reduce youths' SSB consumption.

Efficacy of school-based interventions aimed at decreasing sugar-sweetened beverage consumption among adolescents: a systematic review

Objective

To verify the efficacy of school-based interventions aimed at reducing sugar-sweetened beverage (SSB) consumption among adolescents in order to develop or improve public health interventions.

Design

Systematic review of interventions targeting adolescents and/or the school environment.

Setting

The following databases were investigated: MEDLINE/PubMed, PsycINFO, CINAHL and EMBASE. Proquest Dissertations and Theses was also investigated for unpublished trials.

Subjects

Adolescents were defined as individuals between the ages of 12 and 17 years.

Results

A total of thirty-six studies detailing thirty-six different interventions tested among independent samples (n152 001) were included in the review. Twenty interventions were classified as educational/behavioural and ten were classified as legislative/environmental interventions. Only six interventions targeted both individuals and their environment. Over 70 % of all interventions, regardless of whether they targeted individuals, their environment or both, were effective in decreasing SSB consumption. Legislative/environmental studies had the highest success rate (90·0 %). Educational/behavioural interventions only and interventions that combined educational/behavioural and legislative/environmental approaches were almost equally effective in reducing SSB consumption with success rates of 65·0 and 66·7 %, respectively. Among the interventions that had an educational/behavioural component, 61·5 % were theory-based. The behaviour change techniques most frequently used in interventions were providing information about the health consequences of performing the behaviour (72·2 %), restructuring the physical environment (47·2 %), behavioural goal setting (36·1 %), self-monitoring of behaviour (33·3 %), threat to health (30·6 %) and providing general social support (30·6 %).

Conclusions

School-based interventions show promising results to reduce SSB consumption among adolescents. A number of recommendations are made to improve future studies.

The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review

Poor diet generates a bigger non-communicable disease (NCD) burden than tobacco, alcohol and physical inactivity combined. We reviewed the potential effectiveness of policy actions to improve healthy food consumption and thus prevent NCDs. This scoping review focused on systematic and non-systematic reviews and categorised data using a seven-part framework: price, promotion, provision, composition, labelling, supply chain, trade/investment and multi-component interventions. We screened 1805 candidate publications and included 58 systematic and non-systematic reviews. Multi-component and price interventions appeared consistently powerful in improving healthy eating. Reformulation to reduce industrial trans fat intake also seemed very effective. Evidence on food supply chain, trade and investment studies was limited and merits further research. Food labelling and restrictions on provision or marketing of unhealthy foods were generally less effective with uncertain sustainability. Increasingly strong evidence is highlighting potentially powerful policies to improve diet and thus prevent NCDs, notably multi-component interventions, taxes, subsidies, elimination and perhaps trade agreements. The implications for policy makers are becoming clearer.

Correlates of fruit, vegetable, soft drink, and snack intake among adolescents: the ESSENS study

Background

Identifying modifiable correlates of dietary behaviors is of utmost importance for the promotion of healthy dietary behaviors.

Objective

This study explores individual, home, and school/neighborhood environmental correlates of dietary behaviors (intake of fruits, vegetables, soft drinks, and unhealthy snacks) among adolescents.

Methods

In total, 742 adolescents with a mean age of 13.6 (SD=0.3) were included in this cross-sectional study conducted in 11 secondary schools located in the eastern part of Norway. A web-based questionnaire was used to collect data. Univariable and multivariable linear regression analyses were used to explore factors associated with the dietary behaviors included.

Results

A higher frequency of food/drink purchase in the school canteen was related to a higher consumption of soft drinks and snacks. A higher frequency of food/drink purchase in shops around schools during break or recess was related to a higher consumption of snacks. A higher frequency of food/drink purchase in shops around the neighborhood on the way to and from school was related to a higher consumption of soft drinks. Perceived parental modeling and perceived accessibility at home were found to be positively associated with all dietary behaviors. Perceived parental rules were inversely associated with soft drink and snack consumption; self-efficacy related to healthy eating was positively associated with fruit and vegetable consumption. Other included school and neighborhood environmental correlates were not associated with the dietary behaviors.

Conclusions

There is a need to address the food purchasing behavior of the adolescents using different approaches. The findings also highlight the important role of parents and the home environment for healthy and unhealthy dietary behaviors of adolescents.

Patterns of added sugars intake by eating occasion among a nationally representative sample of Australians

PURPOSE

To examine the eating occasion (EO) where most added sugars (AS) were consumed using a nationally representative dataset.

METHODS

Plausible dietary data from the Australian Health Survey respondents (n = 8202), collected by a multiple-pass 24-h recall, were analyzed. EO was self-reported during the recall. AS content of the foods reported was estimated using a previously published method. Proportion of daily AS consumed (%AS_daily) and the main food sources, at each EO, were calculated. Differences between children/adolescents and adults were tested by one-way ANOVA. Further stratification by age group and sex was performed.

RESULTS

The majority of the %AS_daily came from non-main meal occasions (NMMOs; 48.3 %, 95 % CI 47.5-49.0 %), followed by breakfast/brunch (20.6 %, 95 % CI 20.1-21.1 %). Children and adolescents consumed more %AS_daily during NMMOs compared with adults (52 vs. 47 %; p < 0.001), while girls/women consumed more %AS_daily during NMMO compared with boys (54 vs. 49 %; p = 0.002) and men (50 vs. 45 %; p < 0.001). Sugar-sweetened beverages were the top contributors to AS at lunch, dinner and NMMOs, while sugar and sweet spreads were the top contributor at breakfast/brunch. Other top contributors at NMMOs included "other foods," ice cream and cakes and biscuits, pastries and batter-based products.

CONCLUSION

Australians consumed nearly half of %AS_daily during NMMOs, most of which came from high-sugar energy-dense nutrient-poor foods. While the common perception that most AS come from snacks holds true, our results suggest that main meals are also important intervention targets.

School District Policies and Adolescents' Soda Consumption

PURPOSE

Sugar-sweetened beverages (SSBs) are a significant source of calories and added sugars for youth ages 14-18 years in the United States. This study examined the relationship between district-level policies and practices and students' consumption of regular soda, one type of SSB, in 12 large urban school districts.

METHODS

Data from the 2012 School Health Policies and Practices Study and 2013 Youth Risk Behavior Surveillance System were linked by district. The outcome variable was soda consumption and exposure variables were district policies. We used multivariable logistic regression analyses to calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) after controlling for student characteristics and district free/reduced-price meal eligibility.

RESULTS

About 18% of students reported consuming regular soda at least once per day. Most districts required high schools to have nutrition education, maintain closed campuses, and required/recommended that schools restrict promotional products and sale of beverages. Fewer districts required/recommended that schools offer healthful alternative beverages. Students in districts that restricted promotional products had lower odds of regular soda consumption (AOR = .84, 95% CI = .71-1.00), as did students in districts that restricted access to SSBs and offered healthful beverages when other beverages were available (AOR = .72, 95% CI = .54-.93, AOR = .76, 95% CI = .63-.91).

CONCLUSIONS

This study demonstrates that certain district-level policies are associated with student consumption of regular soda. These findings add to a growing consensus that policies and practices that influence the availability of healthier foods and beverages are needed across multiple settings.

Association Between Student Purchases of Beverages During the School Commute and In-School Consumption of Sugar-Sweetened Beverages, San Francisco Bay Area, 2013

INTRODUCTION

Consumption of sugar-sweetened beverages (SSBs) such as sodas, fruit-flavored drinks, and sports drinks is a major contributor to childhood obesity. One strategy to reduce children's SSB consumption has been to restrict the sale of SSBs in schools. However, such policies may not sufficiently curb students' SSB intake, because students can obtain SSBs elsewhere, including from stores located on their school commute. Little is known about students' purchases of beverages during the school commute or about whether this purchasing behavior is related to in-school SSB consumption. The objective of this study was to describe where students from low-income, ethnically diverse communities obtain the SSBs they drink during school lunchtime and to examine whether students who purchase beverages while traveling to and from school are more likely to drink SSBs during school lunchtime.

METHODS

We analyzed survey data from a random sample of low-income, ethnically diverse middle school students (N = 597) who participated in a randomized controlled trial of a water promotion intervention. We used logistic regression analysis to examine the association between students' purchase of beverages during the school commute and their SSB consumption during school lunchtime.

RESULTS

One-fifth (20.4%) of students drank an SSB during lunch. Approximately 23% of SSBs were obtained during the school commute. Students who reported buying beverages during their school commute (50.1% of all students) were more likely to report drinking SSBs during lunch than students who reported that they do not buy beverages during the school commute (adjusted odds ratio 3.32, 95% confidence interval, 2.19-5.05, P < .001).

CONCLUSION

Students' purchase of beverages during the school commute was strongly associated with SSB consumption during school lunchtime. Interventions could benefit from focusing on retail environments (e.g., encouraging retailers to promote healthy beverages, posting beverage calorie information).

Studying the consumption and health outcomes of fiscal interventions (taxes and subsidies) on food and beverages in countries of different income classifications; a systematic review

Background

Governments use fiscal interventions (FIs) on food and beverages to encourage healthy food behaviour and positive health outcomes. The objective of this review was to study the behavioural and health outcomes of implemented food and beverage FIs in the form of taxes and subsidies in countries of different income classifications.

Methods

The present systematic review was conducted in accordance with Cochrane protocols. The search was carried out on academic and grey literature in English, for studies conducted in different countries on implemented FIs on food and non-alcoholic beverages and health outcomes, with a special focus on the income of those countries.

Results

Eighteen studies met the inclusion criteria and 14 were from peer- reviewed journals. Thirteen studies came from high-income (HI) countries, four from upper middle-income (UMI) countries and only one came from a lower middle-income (LMI) country. There were no studies from lower-income (LI) countries. Of these 18 studies; nine focused on taxes, all of which were from HI countries. Evidence suggests that FIs on foods can influence consumption of taxed and subsidized foods and consequently have the potential to improve health.

Conclusion

Although this review supports previous findings that FIs can have an impact on healthy food consumption, it also highlights the lack of evidence available from UMI, LMI and LI countries on such interventions. Therefore, evidence from HI countries may not be directly applicable to middle-income and LI countries. Similar research conducted in middle and low income countries will be beneficial in advocating policy makers on the effectiveness of FIs in countering the growing issues of non-communicable diseases in these countries.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-2201-8) contains supplementary material, which is available to authorized users.

Reducing Sugar-Sweetened Beverage Intake Among Students: School-Based Programs and Policies That Work

The amount of sugar-sweetened beverages (SSBs) consumed by U.S. youth has nearly doubled since the 1970s. The majority of children between 2 and 19 years drink SSBs on any given day. Many serious health problems such as childhood overweight and obesity, type 2 diabetes, kidney disease, and cardiovascular problems have been linked to SSBs. This article provides an overview of school-based interventions and policies that have successfully contributed to a reduction in sugar-sweetened intake among children. School nurses and nurses in other community-based settings are well positioned to promote intake of more healthful beverages among children using strategies recommended in this article.

Is Sugar the new Tobacco? Insights from Laboratory Studies, Consumer Surveys and Public Health

In the Americas, mean energy intake from added sugar exceeds recent World Health Organization recommendations for free sugars in the diet. As a leading contributor to this excess, sugar-sweetened beverage (SSB) overconsumption represents a risk for the population's health. This article provides an overview of clinical and epidemiological evidence, marketing practices, corporate influence and prevention strategies related to added sugar and SSB. For each aspect of this multidimensional profile, we briefly compare SSB to the case of tobacco pointing to similarities but also major differences. Tobacco control has demonstrated the effectiveness of long term multifaceted prevention strategies in multiple settings supported by strong public policies which may be applied to the consumption of SSB. However, translating these policies to the specific case of SSB is urgently needed, to inform preventive actions, decide which intervention mix will be used, and evaluate the process and impact of the chosen strategy.

Sugar-containing beverage intake in toddlers and body composition up to age 6 years: the Generation R study

BACKGROUND/OBJECTIVE

Intake of sugar-containing beverages (SCBs) has been associated with higher body mass index (BMI) in childhood. The potential effect of SCB intake during infancy is unclear. We examined the association of SCB intake at 13 months with BMI development until 6 years and body composition at age 6 years.

SUBJECTS/METHODS

This study included 2371 Dutch children from a population-based prospective cohort study. SCB intake at 13 months was assessed using a Food Frequency Questionnaire with validation against 24-h recalls and was standardized for total energy. BMI was calculated from repeated weight and height measurements, and age- and sex-specific s.d. scores were calculated. Adiposity was measured using Dual-energy X-ray absorptiometry.

RESULTS

In girls, higher SCB intake at 13 months was significantly associated with higher BMI at ages 2, 3, 4 and 6 years (at age 6 years BMI (s.d. score) increase 0.11 (95% confidence interval (CI) +0.00; 0.23), high versus low intake). We observed a tendency towards higher android/gynoid fat ratio in girls with high intake (s.d. increase 0.14 (95% CI -0.02; 0.29), versus low intake) but not with body fat percentage. In boys, there was no association with BMI or body composition, but boys with high SCB intake at 13 months were taller at age 6 years (s.d. increase 0.14 (95% CI +0.00; 0.27), versus low intake).

CONCLUSIONS

Higher SCB intake at 13 months was associated with higher BMI up to age 6 years in girls but not in boys. Our results imply that the unfavorable effects of SCB intake start early in life and that dietary advice regarding limiting SCB intake should already be given early in life.

The association of soda sales tax and school nutrition laws: a concordance of policies

OBJECTIVE

The current research examined the association between state disfavoured tax on soda (i.e. the difference between soda sales tax and the tax on food products generally) and a summary score representing the strength of state laws governing competitive beverages (beverages that compete with the beverages in the federally funded school lunch programme) in US schools.

DESIGN

The Classification of Laws Associated with School Students (CLASS) summary score reflected the strength of a state's laws restricting competitive beverages sold in school stores, vending machines, school fundraisers and à la carte cafeteria items. Bridging the Gap (BTG) is a nationally recognized research initiative that provided state-level soda tax data. The main study outcome was the states' competitive beverage summary scores for elementary, middle and high school grade levels, as predicted by the states' disfavoured soda tax. Univariate and multivariate analyses were conducted, adjusting for year and state.

SETTING

Data from BTG and CLASS were used.

SUBJECTS

BTG and CLASS data from all fifty states and the District of Columbia from 2003 to 2010 were used.

RESULTS

A higher disfavoured soda sales tax was generally associated with an increased likelihood of having strong school beverage laws across grade levels, and especially when disfavoured soda sales tax was >5 %.

CONCLUSIONS

These data suggest a concordance between states' soda taxes and laws governing beverages sold in schools. States with high disfavoured sales tax on soda had stronger competitive beverage laws, indicating that the state sales tax environment may be associated with laws governing beverage policy in schools.

How state taxes and policies targeting soda consumption modify the association between school vending machines and student dietary behaviors: a cross-sectional analysis

Background

Sodas are widely sold in vending machines and other school venues in the United States, particularly in high school. Research suggests that policy changes have reduced soda access, but the impact of reduced access on consumption is unclear. This study was designed to identify student, environmental, or policy characteristics that modify the associations between school vending machines and student dietary behaviors.

Methods

Data on school vending machine access and student diet were obtained as part of the National Youth Physical Activity and Nutrition Study (NYPANS) and linked to state-level data on soda taxes, restaurant taxes, and state laws governing the sale of soda in schools. Regression models were used to: 1) estimate associations between vending machine access and soda consumption, fast food consumption, and lunch source, and 2) determine if associations were modified by state soda taxes, restaurant taxes, laws banning in-school soda sales, or student characteristics (race/ethnicity, sex, home food access, weight loss behaviors.)

Results

Contrary to the hypothesis, students tended to consume 0.53 fewer servings of soda/week (95% CI: -1.17, 0.11) and consume fast food on 0.24 fewer days/week (95% CI: -0.44, -0.05) if they had in-school access to vending machines. They were also less likely to consume soda daily (23.9% vs. 27.9%, average difference = -4.02, 95% CI: -7.28, -0.76). However, these inverse associations were observed primarily among states with lower soda and restaurant tax rates (relative to general food tax rates) and states that did not ban in-school soda sales. Associations did not vary by any student characteristics except for weight loss behaviors.

Conclusion

Isolated changes to the school food environment may have unintended consequences unless policymakers incorporate other initiatives designed to discourage overall soda consumption.

Associations between the school food environment, student consumption and body mass index of Canadian adolescents

BACKGROUND

Increasing attention has been paid to the school food environment as a strategy to reduce childhood obesity. The purpose of this study was to examine associations between the school food environment, students' dietary intake, and obesity in British Columbia (BC), Canada.

METHODS

In 2007/08, principal responses about the school environment (N=174) were linked to grades 7-12 students (N=11,385) from corresponding schools, who participated in the BC Adolescent Health Survey. Hierarchical mixed-effect regression analyses examined the association between the school food environment and student's intake of sugar-sweetened beverages (SSBs), food consumption, and body mass index. Analyses controlled for school setting, neighborhood education level and student's age and sex.

RESULTS

School availability of SSBs was positively associated with moderate (Odds Ratio (OR)=1.15, 95% Confidence Interval (CI)=1.02-1.30) and high (OR=1.43, 95% CI=1.13-1.80) SSB intake as were less healthful school nutrition guidelines for moderate SSB consumers only (OR=0.65, 95% CI=0.48-0.88). Availability of SSBs at school and its consumption were positively associated with student obesity (OR=1.50, 95% CI=1.12-2.01 and OR=1.66, 95% CI=1.19-2.34, respectively) but not with overweight. In contrast, consumption of less healthful food was positively associated with overweight (OR=1.03, 95% CI=1.01-1.06).

CONCLUSIONS

The results of this study provide further evidence to support the important role of schools in shaping adolescents' dietary habits. Availability and consumption of SSBs, but not less healthful foods, at school were associated with higher adolescent obesity highlighting that other environments also contribute to adolescent obesity.

What proportion of preschool-aged children consume sweetened beverages?

BACKGROUND

Obesity affects nearly 17% of US children and youth 2-19 years old and 10% of infants and toddlers under the age of 2 years. One strategy for addressing obesity is to discourage sugar-sweetened beverage (SSB) consumption. Compared with their older school-aged counterparts, children ≤ 5 years depend largely on parents for the purchase and serving of SSBs. Therefore, recognizing parental factors associated with children's intake of SSBs is important.

METHODS

This study used cross-sectional data from parents of children ≤ 5 years old to examine SSB consumption and associated factors. Elements of the Health Belief Model and Theory of Reasoned Action facilitated data analysis and interpretation.

RESULTS

The most consistent predictor of SSB intake was child age. Nearly 94% of children aged 3-5 years consumed sweetened milk products, 88% consumed fruity drinks, 63% consumed sodas, and 56% consumed sports drinks and sweet tea. Adjusting for all other factors, the only parental psychosocial factor associated with SSB intake was self-efficacy (predicting fruity drinks consumption).

CONCLUSIONS

More children drink SSBs as they get older. Interventions designed to prevent SSB consumption should occur early, before children reach preschool age. Additional study of parental factors influencing SSB intake in early childhood is recommended.

The “Sugar Pack” Health Marketing Campaign in Los Angeles County, 2011-2012

As part of a comprehensive approach to combating the obesity epidemic, the Los Angeles County Department of Public Health launched the “Sugar Pack” health marketing campaign in fall 2011. Carried out in three stages, the campaign sought to educate and motivate the public to reduce excess calorie intake from sugar-sweetened beverage consumption. The primary Sugar Pack creative concepts provided consumers with information about the number of sugar packs contained in sugary drinks. Data from formative market research as well as lessons from previous campaigns in other U.S. jurisdictions informed the development of the materials. These materials were disseminated through a multipronged platform that included paid outdoor media on transit and billboards and messaging using social media (i.e., Twitter, Facebook, YouTube, and sendable e-cards). Initial findings from a postcampaign assessment indicate that the Sugar Pack campaign reached broadly into targeted communities, resulting in more than 515 million impressions. Lessons learned from the campaign suggest that employing health marketing to engage the public can lead to increased knowledge, favorable recognition of health messages, and self-reported intention to reduce sugar-sweetened beverage consumption, potentially complementing other obesity prevention strategies in the field.

Simulation modeling of policies directed at youth sugar-sweetened beverage consumption

Childhood obesity is a significant public health problem requiring innovative solutions. While recent reviews indicate that some policies show promise, there is a lack of information regarding which policies, and policy combinations, work best. Low-nutrition, energy-dense foods and beverages such as sugar-sweetened beverages (SSBs) have been identified as a major contributor to the problem. The purpose of this paper is to use simulation modeling to show how changes in three categories of SSB policies-school nutrition, school-based education, and taxes-impact SSB and other food consumption. The model shows that policies directed at SSBs, particularly tax hikes, could lead to substantial reductions in the number of calories consumed by youth. The estimates, however, are subject to a high degree of uncertainty. Estimates from school-based nutrition and school-based education policies, while also helping to reduce caloric intake, generally show smaller effects than tax policies and considerable variation around parameter estimates for individual and combined policies. We conclude with a discussion of the limits of the model, and suggest where additional information is needed. Limitations notwithstanding, simulation modeling is a promising methodology that can help advance our understanding of policy effects, thereby helping policymakers to better formulate effective policies to reduce obesity prevalence and the associated social harms.

Survey of antiobesity legislation: are these laws working?

PURPOSE OF REVIEW

Obesity is well recognized as a major public health crisis throughout the USA. In recent years, governmental bodies at the federal, state and local levels have enacted policies intended to prevent the transition to obesity. Researchers have had the opportunity to study these policies and evaluate their impact on prevention of obesity.

RECENT FINDINGS

Most public policies have been directed principally, but not exclusively, to the prevention of obesity in school-age children. Interventions have been directed to encouraging breast-feeding, to changing school lunches, limiting access to sugar-sweetened beverages, encouraging physical activity, changing the composition of competitive foods and affecting food advertising directed at children as well as collecting BMI information. Efforts more directed at adults include encouraging workplace wellness programs and improving the nutrition label on packaged foods with front-of-package labels and caloric information on restaurant menus.

SUMMARY

For the most part, evaluations of the interventions reveal weak or modest benefits. The actual picture might be less positive due to the poor quality of research and publication bias. Push back by industry and others will require higher quality experimental and real world studies. All interventions fail to accommodate the multifactorial aspects of obesity.

Recommendations for healthier hydration: addressing the public health issues of obesity and type 2 diabetes

Given the rapid increase in the prevalence of overweight, obesity, type 2 diabetes and other obesity-related conditions across the world, despite a plethora of evidence-based guidance for clinicians, innovative campaigns aimed at the general public and widespread government public health initiatives, it is clear that a novel approach is required. The importance of fluid intake has been overlooked in campaigns and guidelines and also in the clinical setting, where the question 'what do you drink?' is often omitted. It is a significant oversight that food pyramids and healthy-eating plates across the world omit fluids from their graphics and advice. While guidelines include recommendations on changes in physical activity and diet, often little or no advice is offered on the importance of healthier hydration practices, neglecting to highlight the contribution of beverages high in sugar, alcohol or additives. An interdisciplinary group of experts in medicine, nutrition, physiology and public health discussed issues surrounding healthy-hydration practices in March 2010 in Paris to create a consensus statement on hydration and gain of body weight and provide recommendations.