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Preventing Obesity Through Multilevel Interventions to Decrease

SSB Consumption

Brianne E. Kondratowicz

University of Connecticut
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Introduction
Sugar-sweetened beverage consumption among children of the United

States is under scrutiny as a contributor to risk of obesity. According to The

National Health and Nutrition Examination Survey data from 2003-2004, the

primary source of added sugars in the American diet is sugar-sweetened

beverages (SSB). 1The present paper will review the evidence regarding SSB

consumption, poor dietary quality, and risk of obesity. SSB may contribute to

excess energy intake because liquid calories may not be as satiating as solid

calories. The Dietary Guidelines of 2015 placed an emphasis on moving

towards healthier food and beverage choices, specifically ones with low

added sugar. The goal is to have less than 10% of calories come from added
2
sugar.

From Youth Risk Behavior Surveillance System 2015, 73.8% of high

school students reported consuming at least one can or bottle of soda in the

previous 7 days of the survey and 20.4% reported consuming one or more

bottles a day in the previous 7 days. 3According to the National Health and

Nutrition Examination Survey, approximately 20% of calories in childrens

4
diets are obtained from their beverage intake. In a meta-analysis of 15

cohort studies involving children, the consumption of one SSB increment a

5
day lead to a 0.06-0.05-unit increase in BMI.

The present paper will explore the hypothesis that children who

consume too many calories from sugar-sweetened beverages have poorer

dietary quality, excessive energy intake and greater risk of excessive

adiposity. These beverages are marketed to children and families, which

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makes them more appealing than healthier options. This appeal also is

reinforced by the fact that these beverages are often commercially cheaper

than water. Effective interventions must be implemented on the individual,

community and policy levels to ensure reduction in sugar sweetened

beverage consumption. Providing education on the individual level and

decreasing access to sugar sweetened beverages are intervention strategies

that could be used to decrease consumption of sugar sweetened beverages.

Access to sugar sweetened beverages at schools as well as the convenience

of vending machines encourages their consumption among younger

populations. Policy changes could help reduce SSB consumption including

the implementation of stricter laws on marketing of these beverages

specifically to children as well as taxes on them to discourage buying. This

paper will address the hypothesis by covering the following major topics: the

effects of sugar-sweetened beverages on diet quality, excessive energy

intake and greater risk to become overweight as well as the marketing of

SSB and the affordability of SSB.

Poor Diet Quality of Children Related to SSB Intake

This section will examine how the intake of sugar-sweetened

beverages affects overall diet quality in children. Peer-reviewed research on

this topic was obtained by searching (diet quality OR dietary quality)

AND sugar sweetened beverages in PubMed. SSB intake has been related

to poorer diet quality as SSB displace nutrient dense foods and beverages in
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childrens diets. For example, increased intake of SSB has been linked to

decreased intake of milk in children as well as adults. 6

A meta-analysis of cross-sectional studies revealed that 13 out of 15

studies found an association between lower milk and dairy consumption and

increased SSB consumption. In the same meta-analysis, of 18 studies

reporting on carbohydrate intake and SSB consumption, 11 found a positive

correlation between the two. One study found that children and adolescents

in the highest quartile of SSB consumption consumed anywhere from 122-

159 grams of added sugar daily exceeding the U.S. Department of

Agriculture recommendations for added sugar by almost 4 to 5 times.

Associations of SSB consumption with added sugar, sucrose and fructose

were 0.18, 0.23 and 0.36 respectively revealing that added sugar had the

greatest effect on overall increased carbohydrate consumption associated

with SSB. Other studies reported negative associations of SSB consumption

with dietary fiber intake as well as starches. In addition, SSB consumption

was found to be associated with decreased protein, fruit juice, fruit and

riboflavin intake. 6This meta-analysis poses a major limitation, as all the

studies are cross sectional meaning causation cannot be inferred from any of

the studies. Though they can show strong associations, there

The relationship between SSB and poorer diet quality is complex in that

there are associations, but more evidence may be needed. For instance,

there is an association between SSB intake relating to lower calcium intake,

but the effect sizes studied were small. Theres also some evidence that SSB
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also can be an indicator for a poorer diet as those who consume more SSB

have poorer diets in general. The consumption of sweetened beverages can

effect peoples desire to consume other non-nutritious foods.

A cross-sectional, observational study, that was included in the meta-

analysis, hypothesized that an increased intake of bakery products,

sweetened soft drinks and yogurt is related to an increased intake of energy,

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saturated fats, sugar and poor overall diet quality among Spanish children.

The study group was 1,112, six to seven year old children in four Spanish

cities who completed a food frequency questionnaire to assess nutrient and

food intake and calculate healthy eating index (HEI), a measure of diet

quality. 8SSB were defined as carbonated and non-carbonated beverages, but

did not include 100% natural fruit juices. From the analysis, higher

consumption of SSB was associated with lower consumption of milk and

calcium, poorer overall diet quality, elevated energy intake, but no

significant association with BMI. Though SSB was related to poor diet quality,

the difference in HEI scores between the low and high quintiles of SSB was

not significant.

Surprisingly, overall consumption of dairy increased with SSB, despite the

decrease in fluid milk consumption. The decreased HEI score is likely

associated with the decreased milk and Ca intake.

In summary, the effects of bakery goods, yogurt and SSB on Spanish

childrens diet quality is moderate, though still associated with negative

health characteristics and therefore the consumption of these items should

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still be monitored. 7This study did have limitations seeing as though it only

involved 6-7 year old children in four Spanish cities, which is not a very

diverse and inclusive sample population.

Similar to HEI, a Healthy Beverage Index (HBI) was created to help

assess overall beverage quality in relation to daily energy and fluid needs

according to the standards set by the Dietary Guidelines for Americans and
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the Beverage Guidance Panel. A six month, community based, controlled

behavioral trial involved how many participants 18 years or older who

consumed at least 200 kcal/day from SSB prior to the trial. There was a

significant correlation between the HEI and HBI scores. Individuals who

consumed SSB and had high HBI scores received more calories from these

beverages, consumed less healthy beverage options and had overall less
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healthy diets. Though this study primarily focused on adults, these results

would most likely remain consistent with children and additional studies

should be done to prove this.

The DONALD study, an open cohort study from the Research Institute

of Child Nutrition in Germany, found a negative association between SSB

consumption and nutrient intake resulting in poorer diet quality. The study

was established in 1985 and primarily aimed to collect information on

nutrition, development, metabolism and health status of individuals from

infancy to early adults. Three days of dietary records were collected from

7740 number of participants ages 2-19 with detailed records of food

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consumed and leftovers to the nearest gram as weighed by an electric scale.

11

SSB intake was positively associated with energy from carbohydrates

in both boys and girls. In addition, protein and fat intake decreased with

increased SSB consumption for both sexes. In regards to micronutrients,

levels varied by sex. For boys, there was decreased intake of a variety of

micronutrients and was associated with decreased overall diet quality scores.

The lowered effect of SSB on diet quality in boys suggests that SSB most

likely did not displace any nutrient dense foods in the diet. Instead, SSB were

probably consumed in addition to a normal diet in most boys.

In girls, SSB consumption was negatively associated with intake of

nutrients therefore for girls SSB displaced more nutritious foods or lead to

increased consumption of nutrient poor foods. Particularly with Ca intake,

results were consistent with previous studies finding that Ca intake is

significantly lower in those that consume SSB than those that do not. Ca is

important for CVD prevention as well as bone health. 11

In conclusion, the DONALD study shows associations between

increased carbohydrate intake, decreased protein and fat intake and

decreased micronutrient intake overall with SSB intake. Therefore these

associations suggest a correlation between SSB intake and poor diet quality.

There are some limitations to the study though, that need to be pointed out:

dietary information was self reported which can result in inaccurate

recordings and the complex design of the study results in a smaller sample
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size therefore it is not accurately representative with respect to socio-

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economic status.

Consumption of SSB in Children Related to Excessive Energy Intake

This section will examine the associations between intake of SSB and

excess energy intake. Research on this topic was obtained by searching SSB

AND (excess energy intake OR excessive energy intake) in PubMed as

well as finding other references within the citations of articles from PubMed.

Analysis of the nationally-represented National Health and Nutrition

Examination Survey 2007-2012 suggests that replacing one SSB serving a

day with water had a significant impact on the Healthy Beverage Index

scores and weight changes. The study was conducted among adults 19 years

and older and diet data was assessed via a 24-hr recall interview in the

Mobile Exam Center using the USDAs Automated Multiple Pass Method.

Beverages were classified by the HBI. A higher HBI score indicates an overall

healthier beverage intake. Anthropometrics were taken by trained health

professionals during the study.

To model weight loss results in the study, changes in weight from

previously published randomized control trials were used as a guideline. In

statistical models, adults in which one SSB was replaced with water had a

33% energy decrease. With each SSB replaced, the HBI scores lowered.

Older adults who consumed more than 2 SSB a day had the lowest HBI

scores and young adults who did not consume SSB had the highest scores.

Replacing one serving of SSB with water had the most impact among those

who consumed 1-2 SSB a day. Predicted weight changes for those who
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replaced one serving of SSB with water were between -0.4 kg to -1.99 kg

over 8 and 6 months, respectively. Using these predicted values with

individuals heights, there could be a significant estimated reduction in the

cases of obesity and an increase in the number of normal BMIs. 2

In conclusion, overconsumption of SSB could contribute to excessive

energy intake and weight gain. In models, replacing these beverages with

water or other non-SSB could help to reduce energy intake. This study is

limited as it is a statistical model based on cross-sectional data; therefore it

cannot prove cause and effect. In addition, the model is based off adults

rather than children so though similarities can be assumed there is no proof.

Excessive Energy Intake from SSB leads to Greater Risk of High

Adiposity

This section of the paper will explore the association between

excessive energy intake from the consumption of sugar sweetened

beverages resulting in increased adiposity. Information on this topic was

obtained by searching sugar- sweetened beverages AND adiposity as

well as sugar-sweetened beverages AND visceral fat in PubMed.

The relationship between SSB and increased adiposity may be more

complex than just an increase in caloric intake due to the SSB. There is

evidence regarding lack of compensation for SSB in later meals thus

increasing caloric intake, total greater caloric intake in SSB drinkers beyond

the SSB calories indicating a possible link between SSB and satiety and
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6,12,13
relationships between cortisol levels, sugar intake and fat partitioning.

In a cross-sectional study done at the University of Southern California with

overweight or obese adolescents of Hispanic descent of NHB, the

associations between SSB intake, visceral adipose tissue (VAT) and cortisol

awakening response (CAR) in children were studied for the first time. The

researchers hypothesized that high SSB intake would show a dose response

relationship with increasing VAT, increasing SSB related to increased CAR and

the interaction of SSB and CAR would yield differential outcomes on VAT. 14

From the analysis, there was a 7% higher VAT for the high SSB intake

group compared to the low SSB intake group. The high SSB intake group had

a higher CAR than the low SSB intake group. Thus, the results showed,

contrary to the hypothesis, that there was no interactive effect between VAT,

CAR, and SSB directly. Instead, consumption of more than two SSB per day

was independently related to higher VAT and CAR in overweight and obese

minority adolescent participants compared to participants who consumed

less than one SSB a day. The results showed that CAR was the strongest

predictor of VAT and VAT of CAR, but SSB still appeared to influence both and

therefore could be an effective intervention target in trying to reduce CAR

and VAT. The association between SSB and increased CAR levels could be as

a result of chronic elevated cortisol levels possibly related to metabolic

14
dysregulation resulting in an increased desire to consume SSB.

Previous studies have discussed SSB contributing to excess VAT or

increased waist circumference independent of energy intake, but most of the

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research has taken place in adults. Adolescence seems to be a critical time in

VAT accumulation related to SSB intake due to VAT accumulation peaking in

young adulthood in minorities. A longitudinal study found that at SSB

consumption at age 15 was associated with higher BMI and waist

circumference after 6 years. The current cross-sectional study supports these

findings suggesting that consuming more than 2 SSB per day is associated

with increased VAT. It is still unclear the mechanism behind the association of

SSB intake and VAT, but some evidence supports the idea that sweetener
14
type may be involved. A double-blinded parallel randomized trial was

conducted to determine the difference in effects of fructose and glucose on

the body. Fructose is commonly the primary sweetener of soft drinks. The

trial showed that fructose beverages were positively related to increased

VAT. Fructose is directly metabolized by the liver, thus it increases hepatic TG

synthesis and VLDL production and secretion, all of which can lead to an
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increase in VAT.

There are some limitations to this cross sectional study, the one of

utmost importance being that it is a cross sectional study so causality cannot

be inferred. Other limitations include small sample size, sleep not being

taken into account, limited dietary recall and subjects only being Hispanic

and non-Hispanic black. 14

In a cross-sectional study, fructose was examined as a contributing

agent to VAT. This cross-sectional study was phase II of a study carried out on

adolescents in Taiwan. The participants were randomly selected from the

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phase 1 pool of individuals involved in the cross sectional trial studying

multilevel risk profiles for adolescent metabolic syndrome. Dietary

assessments were done on the individuals, which determined which level of

SSB consumption category they were put in (1-350, 351-750 or >750 mL/d.)

There were two main types of SSB consumed: hand shaken sugar containing

drinks (HSDs), which are mainly sweetened with high fructose corn syrup

(HFCS), and bottled sugar-containing drinks (BSDs), which are sweetened

mainly with sucrose and only some with fructose. Anthropometric data were

measured and collected from the participants. Blood samples were taken

from the participants following a 10 hour overnight fast to determine fasting

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plasma glucose.

There was a significantly higher energy intake in those who consumed

the highest level SSB compared to the lower levels of SSB intake. The

analyses also showed that the heavy fructose sweetened beverages were

consumed the most across all participants compared to other sweetened

beverage types. One of the main findings in regards to VAT and SSB in this

study was the correlation between waist circumference (WC) and SSB. WC is

the best marker of VAT in young adults. 17This study found that central

obesity-associated WC accounted for approximately 25% of the excess effect

of consuming more than 350 mL/d of heavy HFCS containing HSD on insulin
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resistance. Similar results were found in an adolescent study that found

associations between visceral fat and participants who consumed fructose

beverages in regards to increases in blood pressure, fasting blood glucose,

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HOMA-IR and C reactive protein. The findings from this study suggested that

the increase in these cardiometabolic markers is dependent on visceral

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obesity.

Again, a limitation to this data is that it is cross sectional, so causation

cannot be inferred. Strong associations though can be seen from the data

between VAT and SSB consumption though.

Marketing of SSB

Targeted marketing of beverages towards children

This section of the paper will explore the targeted marketing of SSB

towards children and how this influences consumption patterns. Information

supporting this idea was found by searching SSB marketing AND children

or adolescents, SSB advertisements AND children as well as, media

and SSB AND children in PubMed.

A cross-sectional study used an online home survey to assess

adolescents self reported frequency of exposure to SSB advertisements. The

survey asked about advertising exposure to the four following categories of

SSB: soda, fruit drinks, sports drinks and energy drinks. Participants were

asked the frequency at which they were exposed to advertisements for these

products. Just over half of the adolescents reported seeing ads for soda

everyday with between 42 and 46% of adolescents seeing fruit drinks, sports

drinks and energy drinks advertised daily. About 1 in 4 adolescents reported

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exposure to advertisements for all four SSB more than one time a day.
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Further analysis should be done on the influence that these advertisements

have on children and their SSB consumption. Overall though, it does seem

like there is strong evidence supporting that SSB ads target children due to

the frequency in which these ads are reported as seen by children.

Targeted marketing of beverages towards parents

This sub section will focus on the targeted marketing of SSB towards

parents and how this effects their childrens SSB consumption. Information

for this section was found by searching SSB marketing AND parents or

caregivers, SSB advertisements AND parents as well as, media and

SSB AND parents in PubMed.

In a cross-sectional study conducted via phone interviews, parents

beliefs about SSB and their exposure to SSB advertisements were studied in

relation to their SSB consumption. 19 Exposure to television food and

beverage ads has been associated to childrens food preferences and

behaviors in the past, but often what is not taken into consideration is
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parents exposure to advertising in relation to childrens consumption. The

phone survey targeted a representative sample of Philadelphia households

with children ages 3-16 years. Participants were asked questions to

determine their average daily consumption of SSB as well as their childs,

type of SSBs consumed, opinion on the healthiness of these beverages,

number of SSB advertisement exposures in the past week, and the number
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of anti-SSB PSAs exposed to in the past week. The figure below shows the
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results of the parent reported SSB advertisement exposures.

The study found associations between exposure to SSB advertisements

and increased SSB consumption. For the parent, SSB advertisements were

related to increased consumption of soda, sweetened tea and fruit drinks. For

children, the parents SSB ad exposure was related to greater consumption of

sweetened teas and sports drinks. Anti-SSB advertisements did not influence

SSB consumption for either group. 19

There were limitations to this study that should be considered. The

study itself involved a small sample size of participants, which prevents the

results to be generalized. In addition, self-reporting was the primary means

of data attainment, which can be inaccurate. In regards to self reporting,

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serving sizes and measurements are likely to be inaccurately reported due to

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there being no standard measuring protocol implemented.

Affordability of Sugar-Sweetened Beverages related to Consumption

This section of the paper will discuss the appeal of SSB related to SSB

often being more affordable than alternative healthier beverages.

Information for the following section was found by searching SSB

consumption and low income in PubMed.

A cross-sectional study in the form of a survey was administered

parents of children in grades 1 or 3 in North East Victoria examining their

eating patterns. The survey asked about their consumption of various foods

and beverages on a typical day as well as demographics. The survey was

used to analyze correlations between childrens fruit and vegetable intake on

their consumption of other foods or drinks. The results of this study found

that there was small positive correlation between fruit intake and water

consumption and a small negative correlation between vegetables and

consumption of soft drinks. They found a positive correlation between the

agreement with the statement that fruits and vegetables cost too much and

the consumption of sugar filled snacks and drinks in health care card holders

(low income individuals.) When observing beverage consumption of those

with health care cards, children consumed fewer servings of water and

increased fruit juice consumption. In addition, there was a higher

consumption of sweetened beverages by children in families with health care

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cards. What this study shows is that there is an association between low

income families and sugar sweetened beverage consumption and purchases.

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More research needs to be done to see if the reasoning for this is directly

related to the cost of the SSB being more affordable or if other factors such

as lack of nutritional knowledge or lack of nutritional care or play a role in the

increased consumption of SSB by lower income populations.

Interventions
This section of the paper explores interventions that could reduce SSB

consumption in children to help combat the negative health effects. The

interventions are on the individual level, community level and policy level.

For the individual level, the main intervention being explored is education

about SSB health risks. Information for this topic was found by searching

health literacy AND SSB and education AND SSB. On the community

level, decreasing access to SSB for children, specifically in schools and

vending machines will be discussed. Sources of information for this section

were found through a systematic review article on nutrition interventions

found when searching for individual interventions. As for the policy level,

putting restrictions on marketing SSB towards children and implementing

taxes on SSB to discourage buying and consumption will be examined.

Individual Intervention -Education

A cross sectional survey was conducted in the Lower Mississippi Delta

region to assess health literacy and see if there was an association between

health literacy and HEI scores as well as SSB consumption. 22 The definition of

health literacy used was the degree to which individuals have the capacity

to obtain, process and understand basic health information and services

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needed to make appropriate health decisions. 23 The survey consisted of a

regional food frequency questionnaire and the Newest Vital Sign used to

assess health literacy. The results of the study found that 73.9% of

participants scored within the two lowest health literacy categories. It also

found that with every 1 point increase in health literacy, there was an

associated 1.21 point increase in HEI scores. Health literacy scores were

significantly associated with SSB consumption. With every 1 point increased

in health literacy scores an associated 34 fewer kilocalories were consumed

from SSB per day. 22 The findings from this study suggest that there is a

strong correlation between individuals health literacy knowledge and their

consumption of SSB, therefore providing individuals with accessible

education about the health risks associated with SSB may have a dramatic

impact on decreasing SSB consumption. Education about SSB should be

provided to both the caregiver/parent who would be providing the child with

SSB as well as the children who to ensure they are aware of how to make

healthy beverage decisions on their own.

In recent years, US states have been working to implement bills that

would require SSB to display health warning labels on them. A cross sectional

study via an online survey was conducted to determine the effective these

labels may have on influencing parents perceptions of SSB and likelihood to

purchase them. The hypothesis being tested was that warning labels would

be more likely to increase perceptions of the health risks associated with

SSBs and reduce the intended purchase of SSB relative to calorie labels or no
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labels. The survey involved a vending machine task in which parents were to

imagine they were buying a beverage for their child from a vending machine.

There were 20 beverage options offered to them of varying types with either

warning labels, calorie labels, or no labels on them. They were instructed to

pick one beverage and then moved onto answering questions about the

beverages they had just viewed. They were then asked which beverages

from those shown that they would buy for their child and which they would

like coupons for. They were asked information in regards to their health and

anthropometrics as well. The results from the analysis of the survey found

that those beverages with warning labels in the vending machine task were

less likely to be chosen than the calorie label or no label. The warning labels

caused parents to believe that SSB were less healthy choices for their

children for a variety of reasons. Majority of participants said that warning

labels would change their views about the healthiness of beverages and
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73.3% of participants were in favor of a beverage warning label policy. This

study again shows an association between education on the on SSB in

relation to health influencing parents decisions and potential purchases.

Ensuring parents are properly aware of the health risks that SSB can

contribute to, specifically on the products themselves could have a

significant impact on SSB purchasing by parents and SSB consumption by

children.

A study was conducted to observe changes in adolescents dietary

behavior and evaluate the effects the Korean governments nutritional

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policies indirectly using interrupted time-series study (ITS) methods. ITS

compares data prior to and post interventions using data collected during

random time intervals. Data was collected using the Korea Youth Risk

Behavior Web-based Survey (KYRBWS) from 2005-2009. KYRBWS analyzed

seven indices of dietary behavior, including carbonated beverages and

confectionary consumption. 65,000 students from 1st grade of middle school

to 2nd grade of high school were the targeted subjects of this study. In 2006,

nutrition teachers were hired for schools to begin implementing nutrition

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education and counseling.

Results from the study revealed that in the first year where the

nutrition education and counseling were in place, when the most dramatic

effects should have been visible, there was actually a decrease in the

consumption of fruits, vegetables and milk as well as a insignificant decrease

in the consumption of fast food, instant noodles and confectionary. Therefore

this study suggests that nutrition education was minimally effective on

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improving dietary behaviors in the children studied.

There were a variety of limitations to this study that should be

mentioned. The study was analyzed over five years which is relatively short

period of time to gather secular trends. It was also unclear whether a

particular policy had an effect on each individual who was targeted in the

study. In terms of policies, because multiple were implemented at the same

time it can be unclear which policy resulted in a given result. Despite these

limitations, the study does give valuable insight into secular trends of
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adolescent diet behavior and evaluated the effects of a government nutrition

25
policies using ITS.

These studies suggest that nutrition education for adolescents may not

be an appropriate intervention strategy for decreasing SSB consumption in

children, but nutrition education for adults may be an effective way to reduce

the purchasing of SSB and the likelihood parents will serve these beverages

to children.

Community Interventions- Decrease Access of SSB to Children

An intervention that could be implemented on the community level to

help decrease SSB consumption is decreasing the availability of SSB to

school children. This intervention has been studied in a variety of ways. A

cross-sectional observational study was conducted following school wellness

policy requirements using data from 2007-2009 annual Youth, Education and

Society study conducted by the Institute for Social Research at the University

of Michigan. 600 schools were drawn from 380 school districts to be

representative of all middle schools and high schools in the country. Of the

schools that were sampled, respondents were asked about the students

access to SSB beverages- vending machines, school stores/snack bars and a

la carte in the cafeteria. They were asked about the types of SSB sold at the

facilities. In addition, questions were asked in regards to contracts the

schools had with beverage companies, if they received incentives due to

these contracts, if there were wellness policies in place addressing student

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nutrition or physical activity and if there is nutrition guidelines for food

available during the school day. Results from the study found that of SSB

accessible to students, regular soda was significantly less prevalent that non-

soda for SSBs for both middle schools and high schools. At the beginning of

the study in 2007, 28% of middle school children and 54% of high school

children had access to sodas at school. By 2009, only 15% of middle school

children and 34% of high school students had access to soda in school

showing significant reduction. The decrease for overall SSBs and non-soda

SSB did not reach statistical significance. Schools having an established

wellness policy was not associated with access to SSB, but nutrition

guidelines development was strongly associated with the availability of SSB

in high schools. Schools without nutrition guidelines had increased access to

SSB, soda and non-soda SSB. 26 This study suggests that implementing

nutritional guidelines can be beneficial in decreasing SSB availability. The

question then becomes does decreased SSB access effect SSB consumption?

In the study discussed prior in individual interventions that evaluated

the effectiveness of Korean Nutrition Policies, there were interventions in

place that limited access to SSB for children. In 2006, MEST recommended

banning the sale of carbonated beverages in schools and youth centers to

limit childrens access to these beverages and implemented it by 2007.

Analysis of the survey results showed an 11.1% decrease in carbonated

beverage consumption from 77.6% to 66.5%. There were significant

decreases for each year of the study except for 2008 and 2009. In the year
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before it was enforced, the year where it was recommended to be enforced

and the year is was enforced there were significant decreases suggesting

that the ban was effective in decreasing consumption. More research should
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be done to see if this was a temporary phenomenon or a permanent trend.

A quasi-experimental, nonrandomized study on high school students in

Maine examined the affects of limiting access of SSB on students SSB

consumption. Students completed food frequency questionnaires pre and

post-test to help determine their beverage consumption patterns. Results

showed there was a 40.5% decrease in availability of SSB in intervention

schools versus the control schools (9.4%) pre and post intervention. Despite

the decrease in availability of these beverages though, those students at

intervention schools did not decrease their consumption of SSB compared to

control schools. The results showed that SSB was decreased in all subjects at

both control and intervention schools over time showing that the intervention

did not directly influence the decrease in consumption. Decreases in SSB

were similar between control and intervention schools and ranged from 15-

18% decreases. Though there was no intentional limiting of access to SSB in

control schools, there was a 9.4% decrease in availability of these beverages

making it unknown if the decrease in SSB consumption in the control schools

was attributed to this decrease. In addition, at the time this study was being

preformed, there were 3 state wide policy initiatives being discussed

regarding healthy food choices in Maine public schools that were advertised

and widely known about that could have potentially influenced students
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decisions. An additional limitation to this study includes the fact that food

frequency questionnaire that determined the beverage intake did not only

specify the consumption of SSB only during the school day, which could have

effected the results of the study differently. Another possible limitation is

that the baseline SSB of the individuals being studied was already too low,

making it difficult to have a significant reduction. The sample size itself was

small, non-randomized and primarily white students so the application of this

27
study on a global level would be weak.

The previous study only examined the decreased access to SSB in

schools rather than the elimination of selling SSB in schools, so further

research on potentially banning the sale of SSB in schools could provide

interesting evidence. In addition, studies involving larger sample sizes with a

diverse population could provide more conclusive evidence.

Overall, decreasing access to SSB in schools could have some effect at

reducing SSB consumption, but further research should be done to see how

effective it would be.

Policy interventions- Implementing Taxes on SSB

An intervention strategy on the policy level that is often discussed for

decreasing SSB consumption is the implementation of taxes on SSB to

discourage the purchasing of these beverages. In an observational study in

Mexico using the data from January 2012-December 2014 Nielsen Mexicos

Consumer Panel Services, the purchasing of SSB before and after the
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implementation of an excise tax on SSB in 2014 was studied. Based on

Mexican government statistics, the sample of data collected through the

Nielsen survey represents 63% of the Mexican population and 75% of food

and beverage expenditures in 2014. Because the tax was implemented

nationally, it was impossible to conduct a true experimental design to look at

the association between tax on SSB and purchases, so a pre/post quasi

experimental approach using difference in difference analyses along with

fixed effects models was used in the study. The results found that after

implementing the beverage tax in 2014, there was an average of 6%

decrease in taxed beverage purchases. By December of 2014, there was a

12% decrease in purchases of taxed beverages. The decrease in taxed

beverage purchases was seen most dramatically in low socioeconomic

households with a decrease of 9.1% in January 2014 and 17.4% by

December of 2014. Purchases of non-taxed beverages increased by 4%.

Interestingly, the study found greater reductions in purchases of non-

carbonated taxed beverages compared to taxed carbonated beverages. It is

hypothesized that the reasoning for this is due to the higher prices of
28
noncarbonated SSB.

This study does have some limitations, a major one being that casualty

cannot be determined due to it being an observational study and the

presence of many other changes occurring concurrent with the tax

implementation. Another limitation is that the study only reported on

consumers in Mexico living in cities with 50,000+ residents. This study only
 26

evaluates the short-term effects after the implication of the taxes on SSB, so

it is important that the trends in SSB purchases are continuously monitored

to see if the trend continues. 28

In America, a similar, yet predictive, study was preformed to determine

the effects that taxes on SSB may have on consumption of SSB, specifically

on preschool children. Data from the 2009-2012 Nielsen Homescan Panel

was used to stimulate taxes by increasing the beverages by 10%, 15% and

20%. The study examined the association between simulated price increases

on SSB and a variety of consumer- packaged foods among US households

with preschool children in them. The findings were then extrapolated to

estimate the associations between each beverage tax and annual weight of

foods/beverages purchased per capita. Results found that increasing the

price of SSBs by 10%, 15% and 20% was associated with fewer juice drink

purchases (-1.2 to -2.3 g/d per capita.) There was an association with

greater purchasing of sports and energy drinks with the tax simulation. There

were no significant associations between increase in the SSB prices with the

total weight of purchases. Increases in the prices of SSBs and >1% fat

and/or high-sugar milk were associated with fewer purchases of >1% fat,

low-sugar milk and increased purchases of sport and energy drinks. Though

there were no significant reductions in soft drink purchases with the

theoretical tax implications, there were minor decreases in the predicted

29
purchasing showing a trend in the right direction. Other studies have been

done to study what effects a 20% tax implication could have on SSB
 27

purchases, and one study found associations with a reduction in purchases of

juice drinks and soft drinks and increase in fruit juices purchases 30 while

another also found a decrease in purchases of SSBs but would increase

31
purchases of juice drinks. Overall, this predictive study did have

limitations, the primary one being that the study cannot show causation,

only associations due to the fact that outcomes and primary exposures were

ascertained at the same time. The study suggests there may be associations

with shifts in food and beverage, but even with 20% tax increases, the

reductions were small suggesting that taxes 20% or more may be needed
29
just to make noticeable changes in purchasing habits of families.

The short-term results from the taxing of SSBs in Mexico had promising

associations, and although there were few significant findings from the

predictive study on Americans and the implementation of taxes on SSB, the

trends supported decreases in SSB purchases. Actually implementing taxes

on SSB in the US could yield entirely different results than predicted and

could end up resulting in significant decreases in the purchasing of SSB as

28,29
seen in Mexico.

Conclusions

Childhood obesity and its association with SSB consumption is not a

simple relationship, rather it is part of a socio-ecological model influenced by

a variety of factors on multiple levels. One factor which was eluded to at

various points in this paper is that socioeconomic status effects the

purchasing and consumption of SSB. The USDA released a report updated in

 28

2016 on foods most commonly purchased by SNAP households and non-

SNAP households. For SNAP households, the second most commonly

purchased food item was SSB behind Meat/Poultry/ Seafood, where as in non-

SNAP households, SSB were the 5th most commonly purchased item with

both fruits and vegetables being ranked higher in purchases. There seems to

be an association between the consumption of SSB by those of lower income

levels than those of middle class or higher, which could be attributed to a

variety of reasons including cost of the beverages, nutrition knowledge and

food preferences among other issues. 32 The idea of placing restrictions on

what SNAP funding can be used for could be something worth looking into in

regards to helping restrict SSB among lower income households.

Another factor that plays into the socio-ecological model is the idea of

implementing School Wellness Policies, which was mentioned in the

individual interventions of educating as well as on the community level to

see how these policies affected availability of SSB. The idea of implementing

these types of policies could help educate children on the risks associated

with SSB consumption as well as restrict SSB availability. A quasi-

experimental designed study evaluated the effectiveness of school based

healthy lifestyle interventions strengthening school wellness problems. The

schools had teachers attending nutrition courses to help implement healthy

eating in the classrooms and catered lunch menus to be compliant with the

Healthy Hunger-Free Kids Act among other revisions, and found that the

overall nutritional status of the children studied increased significantly in the

 29

33
follow up evaluations. Seeing significant impacts in school wellness

policies on childrens overall nutritional status suggests that implementing

nutritional knowledge about SSB into wellness policies could have beneficial

nutritional outcomes for children.

Though decreasing the consumption of SSB may not solve the issue of

obesity in America, there is ample evidence and associations supporting the

idea that decreasing SSB could promote weight loss and decrease the

incidence of obesity. Some of the strongest evidence in relation to SSB and

obesity is the associations between SSB consumption and overall poor diet

quality. In addition, the associations between the increased risk of adiposity

with consumption of SSB has significant associations and should continue to

be studied to see if there is anymore evidence to support the relationship.

The interventions mentioned, education, decreased access and taxing SSB

are all interventions that should continue to be studied for they could

significantly impact SSB consumptions and provide substantial results in

controlling obesity related to SSB.

 30

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