Effects of a front-of-package disclosure on accuracy in assessing children's drink ingredients: two randomised controlled experiments with US caregivers of young children

OBJECTIVE

Test effects of a standardised front-of-package (FOP) disclosure statement (indicating added sugar, non-nutritive sweetener (NNS) and juice content) on accuracy in assessing ingredients and perceived healthfulness of children's drinks.

DESIGN

In two randomised controlled experiments, the same participants viewed drink packages and indicated if products contained added sugar or NNS and percent juice and rated drink healthfulness. Experiment 1 (E1) included novel (non-US) children's drinks with a) product claims only (control), b) claims and disclosure, or c) disclosure only. Experiment 2 (E2) included existing children's drinks (with claims) with a) no disclosure (control) or b) disclosure. Both experiments evaluated sweetened (fruit drink and flavoured water) and unsweetened (100 % juice and juice/water blend) drinks. Potential individual differences (education level and race/ethnicity) in effects were explored.

SETTING

Online survey.

PARTICIPANTS

Six hundred and forty-eight US caregivers of young children (1-5 years).

RESULTS

FOP disclosures significantly increased accuracy for most ingredients and drink types, including identifying presence or absence of NNS in sweetened drinks, no added sugar in juice/water blends, and actual percent juice in fruit drinks and juice/water blends in both experiments. Disclosures also increased recognition that the novel 100 % juice and juice/water blend did not contain NNS or added sugar (E1) and existing sweetened drinks contained added sugar (E2). Disclosures reduced perceived healthfulness of sweetened drinks but did not increase unsweetened drink healthfulness ratings. Some differences by participant socio-demographic characteristics require additional research.

CONCLUSIONS

FOP disclosures on children's drink packages can increase caregivers' understanding of product ingredients and aid in selecting healthier children's drinks.

Front-of-package claims & imagery on fruit-flavored drinks and exposure by household demographics

Young children regularly consume sugary fruit drinks, in part because parents may falsely believe they are healthful due to front-of-package (FOP) claims and imagery. The goal of this study was to assess: 1) the prevalence of FOP claims/imagery on fruit-flavored beverages purchased by U.S. households with 0-5-year-olds, and 2) proportional differences in beverages purchased with FOP claims/imagery across household demographic groups. A content analysis of FOP claims/imagery (e.g., nutrient claims, fruit imagery) on beverages (n = 1365) purchased by households with 0-5-year-olds was conducted by linking beverage sales with FOP marketing data. Results were merged with purchasing data from a nationally representative sample of households (FoodAPS), and survey-weighted logistic regression was used to assess differences in the proportions of 100% juices and fruit drinks with specific FOP claims/imagery purchased by household race/ethnicity, income, and SNAP/WIC participation. The most common claims on fruit-flavored beverages included nutrient claims (fruit drinks: 73%; 100% juices: 68%; flavored waters: 95%), which most commonly highlighted vitamin C (35-41% across beverage categories) and the absence of sugar (31-48%). Most beverages also contained implied-natural claims (fruit drinks: 60%; 100% juices: 64%; flavored waters: 95%) and natural imagery (fruit drinks: 97%; 100% juices: 96%; flavored waters: 73%). A large proportion of fruit drinks and 100% juices purchased by households across all demographic groups contained FOP claims and imagery, with a few minor differences between racial/ethnic groups. In conclusion, most fruit drinks, 100% juices, and flavored waters purchased by households with 0-5-year-olds contained FOP claims and imagery that may lead consumers to believe the beverages are healthy and natural. FDA regulations should ensure parents are not misled by this marketing.

High fructose corn syrup, excess-free-fructose, and risk of coronary heart disease among African Americans- the Jackson Heart Study

BACKGROUND

Researchers have sought to explain the black-white coronary heart disease (CHD) mortality disparity that increased from near parity to ~ 30% between 1980 and 2010. Contributing factors include cardiovascular disease prevention and treatment disparities attributable to disparities in insurance coverage. Recent research suggests that dietary/environmental factors may be contributors to the disparity. Unabsorbed/luminal fructose alters gut bacterial load, composition and diversity. There is evidence that such microbiome disruptions promote hypertension and atherosclerosis. The heart-gut axis may, in part, explain the black-white CHD disparity, as fructose malabsorption prevalence is higher among African Americans. Between 1980 and 2010, consumption of excess-free-fructose-the fructose type that triggers malabsorption-exceeded dosages associated with fructose malabsorption (~ 5 g-10 g), as extrapolated from food availability data before subjective, retroactively-applied loss adjustments. This occurred due to an industrial preference shift from sucrose to high-fructose-corn-syrup (HFCS) that began ~ 1980. During this period, HFCS became the main sweetener in US soda. Importantly, there has been more fructose in HFCS than thought, as the fructose-to-glucose ratio in popular sodas (1.9-to-1 and 1.5-to-1) has exceeded generally-recognized-as-safe levels (1.2-to-1). Most natural foods contain a ~ 1-to-1 ratio. In one recent study, ≥5 times/wk. consumers of HFCS sweetened soda/fruit drinks/and apple juice-high excess-free-fructose beverages-were more likely to have CHD, than seldom/never consumers.

METHODS

Jackson-Heart-Study data of African Americans was used to test the hypothesis that regular relative to low/infrequent intake of HFCS sweetened soda/fruit drinks increases CHD risk, but not orange juice-a low excess-free-fructose juice. Cox proportional hazards models were used to calculate hazard ratios using prospective data of 3407-3621 participants, aged 21-93 y (mean 55 y).

RESULTS

African Americans who consumed HFCS sweetend soda 5-6x/wk. or any combination of HFCS sweetened soda and/or fruit drinks ≥3 times/day had ~ 2 (HR 2.08, 95% CI 1.03-4.20, P = 0.041) and 2.5-3 times higher CHD risk (HR 2.98, 95% CI 1.15-7.76; P = 0.025), respectively, than never/seldom consumers, independent of confounders. There were no associations with diet-soda or 100% orange-juice, which has a similar glycemic profile as HFCS sweetened soda, but contains a ~ 1:1 fructose-to-glucose ratio.

CONCLUSION

The ubiquitous presence of HFCS in the food supply may pre-dispose African Americans to increased CHD risk.

Excess free fructose, apple juice, high fructose corn syrup and childhood asthma risk - the National Children's Study

BACKGROUND

Recent research provides consistent evidence that the unexplained doubling of childhood asthma prevalence (1980-1995), its continued climb and 2013 plateau, may be associated with the proliferation of high-fructose-corn-syrup (HFCS) in the US food supply. The HFCS used in soft drinks has been shown to contain a higher fructose-to-glucose ratio than previously thought. This coincides with a preference shift from orange to apple juice among young children. Apple juice naturally contains a high (≥2:1) fructose-to-glucose ratio. Thus, children have received high excess-free-fructose doses, the fructose type associated with fructose malabsorption. Unabsorbed excess-free-fructose in the gut may react with dietary proteins to form immunogens that bind asthma mediating receptors, and/or alter the microbiota towards a profile linked to lung disorders. Studies with longitudinal childhood data are lacking. Therefore, we tested the hypothesis that excess-free-fructose intake is associated with childhood asthma risk.

METHODS

Cox regression models were used to analyze prospective early childhood data (12-30 months of age) from the National Children's Study. Intake frequencies for soda/sports/fruit drinks, and 100% juices were used for analyses.

RESULTS

Greater consumption of 100% juice, soda/sports/fruit drinks, and any combination, was associated with ~two (P = 0.001), ~ 2.5 (P = 0.001), and ~ 3.5 times (P < 0.0001) higher asthma incidence.

CONCLUSIONS

Given these results, prior research and case-study evidence, it is reasonable to suggest that the two-fold higher asthma risk associated with 100% juice consumption is due to apple juice's high fructose-to-glucose ratio, and that the ~ 2.5/~ 3.5 times higher risk associated with soda/sports/fruit drinks intake is with the excess-free-fructose in HFCS.

The impact of front-of-package claims, fruit images, and health warnings on consumers' perceptions of sugar-sweetened fruit drinks: Three randomized experiments

We aimed to examine the impact of claims, fruit images, and health warnings on consumers' perceptions of fruit-flavored drinks with added sugar (i.e., "fruit drinks"). We conducted three 2x2x2 randomized experiments with online convenience samples of U.S. adults (Study 1 n = 2139 in 2018, current e-cigarette users and smokers; Study 2 n = 670 in 2018, current e-cigarette users; Study 3 n = 1006 in 2019, general sample). Participants viewed a fruit drink that differed in the presence of a "100% Vitamin C" claim, a fruit image, or a health warning. On average across the three studies, consumers who saw a claim on a fruit drink believed that the drink was more healthful than those who did not see the claim (mean average differential effect (ADE) = 0.66, p < .001); they were also more interested in consuming the drink (mean ADE = 0.38, p = .001). The health warning decreased perceived product healthfulness (mean ADE = -0.65, p < .001) and consumption interest (mean ADE = -0.49, p < .001). The fruit image had no effect on perceived product healthfulness (mean ADE = 0.03, p = .81) or purchase intentions (mean ADE = -0.04, p = .77). In Study 1 and Study 2, there were no interactions between claims, images, or warnings (all p > .05). In Study 3, the "100% Vitamin C" nutrition claim only increased perceived product healthfulness when the drink did not also have a health warning (interaction p < .05). These findings suggest that 100% Vitamin C claims increase the appeal of fruit drinks, whereas health warnings decrease the appeal. Together, these studies support policies to restrict marketing and require health warnings on sugar-sweetened beverage packaging.

Excess free fructose, high-fructose corn syrup and adult asthma: the Framingham Offspring Cohort

There is growing evidence that intakes of high-fructose corn syrup (HFCS), HFCS-sweetened soda, fruit drinks and apple juice - a high-fructose 100 % juice - are associated with asthma, possibly because of the high fructose:glucose ratios and underlying fructose malabsorption, which may contribute to enteral formation of pro-inflammatory advanced glycation end products, which bind receptors that are mediators of asthma. Cox proportional hazards models were used to assess associations between intakes of these beverages and asthma risk, with data from the Framingham Offspring Cohort. Diet soda and orange juice - a 100 % juice with a 1:1 fructose:glucose ratio - were included for comparison. Increasing intake of any combination of HFCS-sweetened soda, fruit drinks and apple juice was significantly associated with progressively higher asthma risk, plateauing at 5-7 times/week v. never/seldom, independent of potential confounders (hazard ratio 1·91, P<0·001). About once a day consumers of HFCS-sweetened soda had a 49 % higher risk (P<0·011), moderate apple juice consumers (2-4 times/week) had a 61 % higher risk (P<0·007) and moderate fruit drink consumers had a 58 % higher risk (P<0·009), as compared with never/seldom consumers. There were no associations with diet soda/orange juice. These associations are possibly because of the high fructose:glucose ratios, and fructose malabsorption. Recommendations to reduce consumption may be inadequate to address asthma risk, as associations are evident even with moderate intake of these beverages, including apple juice - a 100 % juice. The juice reductions in the US Special Supplemental Nutrition Program for Women, Infants, and Children in 2009, and the plateauing/decreasing asthma prevalence (2010-2013), particularly among non-Hispanic black children, may be related. Further research regarding the consequences of fructose malabsorption is needed.

Development and validation of predictive models for the effect of storage temperature and pH on the growth boundaries and kinetics of Alicyclobacillus acidoterrestris ATCC 49025 in fruit drinks

This study was undertaken to provide quantitative tools for predicting the behavior of the spoilage bacterium Alicyclobacillus acidoterrestris ATCC 49025 in fruit drinks. In the first part of the study, a growth/no growth interface model was developed, predicting the probability of growth as a function of temperature and pH. For this purpose, the growth ability of A. acidoterrestris was studied at different combinations of temperature (15-45 °C) and pH (2.02-5.05). The minimum pH and temperature where growth was observed was 2.52 (at 35 and 45 °C) and 25 °C (at pH ≥ 3.32), respectively. Then a logistic polynomial regression model was fitted to the binary data (0: no growth, 1: growth) and, based on the concordance index (98.8%) and the Hosmer-Lemeshow statistic (6.226, P = 0.622), a satisfactory goodness of fit was demonstrated. In the second part of the study, the effects of temperature (25-55 °C) and pH (3.03-5.53) on A. acidoterrestris growth rate were investigated and quantitatively described using the cardinal temperature model with inflection and the cardinal pH model, respectively. The estimated values for the cardinal parameters T_min, T_max, T_opt and pH_min, pH_max, pH_opt were 18.11, 55.68, 48.60 °C and 2.93, 5.90, 4.22, respectively. The developed models were validated against growth data of A. acidoterrestris obtained in eight commercial pasteurized fruit drinks. The validation results showed a good performance of both models. In all cases where the growth/no growth interface model predicted a probability lower than 0.5, A. acidoterrestris was, indeed, not able to grow in the tested fruit drinks; similarly, when the model predicted a probability above 0.9, growth was observed in all cases. A good agreement was also observed between growth predicted by the kinetic model and the observed kinetics of A. acidoterrestris in fruit drinks at both static and dynamic temperature conditions.

Probiotic strain Lactobacillus plantarum 299v increases iron absorption from an iron-supplemented fruit drink: a double-isotope cross-over single-blind study in women of reproductive age

Iron deficiency is common, especially among young women. Adding probiotics to foods could be one way to increase iron absorption. The aim of this study was to test the hypothesis that non-haem iron absorption from a fruit drink is improved by adding Lactobacillus plantarum 299v (Lp299v). Iron absorption was studied in healthy women of reproductive age using a single-blind cross-over design in two trials applying the double-isotope (⁵⁵Fe and ⁵⁹Fe) technique. In Trial 1, iron absorption from a fruit drink containing 10⁹ colony-forming units (CFU) Lp299v was compared with that from a control drink without Lp299v. Trial 2 had the same design but 10¹⁰ CFU were used. The test and control drinks contained approximately 5 mg of iron as ferrous lactate and were labelled with ⁵⁹Fe (B) and ⁵⁵Fe (A), respectively, and consumed on 4 consecutive days in the order AABB. Retention of the isotopes was measured with whole-body counting and in blood. Mean iron absorption from the drink containing 10⁹ CFU Lp299v (28·6(sd 12·5) %) was significantly higher than from the control drink (18·5(sd 5·8) %), n 10, P<0·028). The fruit drink with 10¹⁰ CFU Lp299v gave a mean iron absorption of 29·1(sd 17·0) %, whereas the control drink gave an absorption of (20·1(sd 6·4) %) (n 11, P<0·080). The difference in iron absorption between the 10⁹ CFU Lp299v and the 10¹⁰ CFU Lp299v drinks was not significant (P=0·941). In conclusion, intake of probiotics can increase iron absorption by approximately 50 % from a fruit drink having an already relatively high iron bioavailability.