Warning Labels Reduce Sugar-Sweetened Beverage Intake among College Students

How does habit strength affect reactions to warning labels? evidence from Chinese consumers' choices of carbonated beverages

Effectively regulating the excessive consumption of sugar-sweetened beverages (SSBs) has been an important task for public health authorities around the world. The rapid increase in SSB consumption in China necessitates robust regulations. This study employed a choice experiment to simulate the market scenario in which a text warning label was presented on SSBs. We draw a sample of 1200 participants from five major cities across China to analyze the warning label's effectiveness in reducing urban consumers' purchases of SSBs, with a particular emphasis on how an individual's habit strength affects their reaction to the warning label. Our analysis unveiled varying levels of habit strength among respondents: 35.33% showed weak habits, 56.25% displayed moderate habits, and 8.42% demonstrated strong habits. The random parameters logit model results showed a significant overall decrease in SSB purchases when a warning label was present, indicated by a significant negative coefficient associated with the label. However, when examining the impact of warning labels across different habit strengths, a significant effect was observed only in the moderate habit group. Furthermore, within this group, the warning label was more effective for those with correct health knowledge and who were not overweight or obese.

How Sugar Labeling Affects Consumer Sugar Reduction: A Case of Sucrose Grade Labels in China

The effectiveness of sugar labeling depends not only on direct sugar reduction but also on the extent to which compensatory eating occurs. This study focuses on the use of sucrose grade labels in the Chinese market to investigate not only consumers' willingness to pay (WTP) for different sucrose labels but also the consistency of their sugar control behavior when confronted with unlabeled processed foods. The findings reveal that consumers are willing to pay approximately 4%, 7%, and 7% more for yogurt labeled as "low sucrose", "no sucrose", and "no sucrose with sugar substitutes", respectively, compared to yogurt labeled as "regular sucrose." Furthermore, when subsequently presented with unlabeled toast, a significant proportion of consumers who initially chose "no sucrose" yogurt continued to select wholewheat toast, which contains less sugar than white and coconut toast. This indicates their commitment to maintaining their sugar control behavior. The study provides valuable experimental evidence for researchers, food manufacturers, and policymakers regarding the efficacy of sucrose grade labels. In particular, it offers policymakers insights into guiding consumers to promote sustainable healthy diets.

Persistent and Changing Food Insecurity Among Students at a Midwestern University is Associated With Behavioral and Mental Health Outcomes

PURPOSE

To assess associations between persistent and changing food insecurity and behavioral and mental health outcomes in college students.

DESIGN

Online surveys conducted November 2018 and March 2019 (freshman year), and March 2020 (sophomore year) were used to assess food insecurity, which was then used to create 4 food security transitions: persistent food insecurity, emergent food insecurity, emergent food security, and persistent food security.

SETTING

Large Midwestern university.

SAMPLE

593 students completing all 3 surveys.

MEASURES

Dietary intake and behavioral and mental health outcomes (eating disorders, anxiety, depression, sleep quality) were assessed using validated instruments.

ANALYSIS

Associations between food security transitions and dietary intake, behavioral, and mental health outcomes were examined using generalized linear models.

RESULTS

Compared to persistent food security, emergent and persistent food insecurity was associated with lower (7% and 13% respectively) intake of fruits and vegetables combined; persistent food insecurity was associated with 17% lower intake of fruits, 6% lower intake of fiber and 10% higher intake of added sugar from beverages. Compared to persistent food secure students, eating disorder symptom risk was higher for emergent food insecure (OR = 7.61, 95% CI: 3.32, 17.48), and persistent food insecure (OR = 6.60, 95% CI: 2.60, 16.72) students; emergent (OR = 2.05, 95% CI: 1.14, 3.71) and persistent (OR = 2.55, 95% CI: 1.34, 4.87) food insecure students had higher odds of poor sleep quality, and persistent food insecure, emergent food insecure, and emergent food secure students had higher odds of anxiety and depression (OR range 2.35-2.85).

CONCLUSION

Food security transitions were associated with aspects of low diet quality and poorer behavioral and mental health outcomes among college students.

Trend in basic oral treatment needs in relation to taxation of sweets, ice cream, and sugar-sweetened beverages in Finland: a registry-based study

OBJECTIVE

The aims were to explore the trend in basic oral treatment needs and total operating cost of public dental services (PDS) in relation to total excise tax revenue generated from sugary products during 2011-2020 and to evaluate the impact of tax policy in excise tax revenue of sugary products and average sugar consumption.

METHODS

The study comprised longitudinal data retrieved from Finnish registries during the years 2011-2020. Basic oral treatment needs, and total operating cost of PDS, total excise tax revenue generated from sugary products and average sugar consumed (kg per capita) during the years 2011-2020 were obtained. Simplified panel analyses and sensitivity analyses were used to evaluate the effects of explanatory variables on outcomes.  Results: An approximate one EUR 1,000,000 increase in total excise tax revenue generated from sugary products corresponds to a 0.4% increase in total operating cost of PDS. There was a significant positive trend in total operating cost of PDS in Finland over the study period. Similarly, an approximate one EUR 1,000,000 rise in total excise tax revenue corresponds to a 0.2% increase in basic oral treatment needs. Additionally, there was a statistically significant difference in the average excise tax revenue for sugary products between the periods before and after 2017.

CONCLUSION

No change in average sugar consumption was observed despite implementing the new sugar policy. Therefore, it may be worthwhile to reconsider the excise tax on sweets and ice cream as it will significantly increase the total national revenues.

Tap water perceptions and water filter use vary with socio-demographic characteristics and are associated with water and sugar-sweetened beverage consumption in university students

OBJECTIVE

The goal of this study is to evaluate university students' perceptions of tap water safety and water filter use and determine how these perceptions and behaviours affect water and sugar-sweetened beverage intake.

DESIGN

Cross-sectional; online survey conducted in Fall 2021.

SETTING

A large, public Midwestern university in the USA.

PARTICIPANTS

Seven-hundred ninety-three university students.

RESULTS

Students who experienced food insecurity, were on a Pell grant, were first-generation college students or were racial/ethnic minorities were less likely to trust tap water safety. Tap water filtration behaviour also varied by age and race/ethnicity. Students who did not agree with the statement 'my local tap water is safe to drink' had lower odds of consuming ≥ 3 cups of total water per day (OR = 0·45, 95 % CI: 0·32, 0·62), lower odds of consuming tap water ≥ 3 times/d (OR = 0·46, 95 % CI: 0·34, 0·64), higher odds of drinking bottled water ≥ 1 time per day (OR = 1·80, 95 % CI: 1·22, 2·66) and higher odds of drinking SSB ≥ 1 time per day (OR = 1·47, 95 % CI: 1·01, 2·14) than those who agreed. Students who always or sometimes filtered their tap water had lower odds of consuming ≥ 3 cups of total water per day (OR = 0·59, 95 % CI: 0·39, 0·90) than students who never filtered their tap water.

CONCLUSIONS

Tap water perceptions and behaviours affect tap and bottled water and SSB intake among university students. Tap water perceptions and behaviours in this demographic provide important context for university programming promoting healthy beverage initiatives.

Online RCT of Icon Added-Sugar Warning Labels for Restaurant Menus

INTRODUCTION

To reduce added-sugar consumption, jurisdictions are considering requiring restaurant menu labels to identify high-added-sugar items. This study examined the impacts of added-sugar warning labels on hypothetical choices, knowledge of items' added-sugar content, and perceptions of high-added-sugar items.

STUDY DESIGN

The design was an online RCT.

SETTING/PARTICIPANTS

National sample of adults (N=15,496) was recruited to approximate the U.S. distribution of sex, age, race, ethnicity, and education.

INTERVENTION

Participants viewed fast-food and full-service restaurant menus displaying no warning labels (control) or icon-only added-sugar warning labels next to high-added-sugar items (containing >50% of the daily recommended limit).

MAIN OUTCOME MEASURES

The main outcome measures were hypothetical ordering of ≥1 high-added-sugar item, grams of added sugar ordered, and knowledge of items' added-sugar content assessed in 2021 and analyzed in 2021-2022.

RESULTS

Warning labels reduced the relative probability of ordering ≥1 high-added-sugar item by 2.2% (probability ratio=0.978, 95% CI=0.964, 0.992; p=0.002); improved knowledge of added-sugar content (p<0.001); and led to a nonstatistically significant reduction of 1.5 grams of added sugar ordered, averaged across menus (p=0.07). The label modestly reduced the appeal of high-added-sugar items, increased perceptions that consuming such items often will increase Type 2 diabetes risk, increased perceived control over eating decisions, and increased injunctive norms about limiting consumption of high-added-sugar items (ps<0.001). However, in the warning condition, only 47% noticed nutrition labels, and 21% recalled seeing added-sugar labels. When restricting the warning condition to those who noticed the label, the result for grams of added sugar ordered was significant, with the warning condition ordering 4.9 fewer grams than the controls (95% CI= -7.3, -2.5; p<0.001).

CONCLUSIONS

Added-sugar warning labels reduced the probability of ordering a high-added-sugar menu item and increased participants' knowledge of whether items contained >50% of the daily value for added sugar. The modest magnitudes of effects may be due to low label noticeability. Menu warning labels should be designed for noticeability.

REGISTRATION

This study was registered at AsPredicted.org #65655.

Effects of Sugary Beverage Text and Pictorial Warnings: A Randomized Trial

INTRODUCTION

Multiple U.S. localities have introduced legislation requiring sugar-sweetened beverage (SSB) warnings. This study effects of different warning designs on beverage selections and perceptions.

STUDY DESIGN

The study was an RCT.

SETTING/PARTICIPANTS

An online virtual convenience store and survey were used with a nationally representative sample of primary caregivers of 6-11-year-olds (n=961). Data were collected in January 2020 and analyzed in May-July 2020.

INTERVENTION

Participants were randomized to view SSBs with 1 of 4 front-of-package label designs: (1) no-warning control, (2) health-related text warning, (3) sugar pictorial warning (image of beverage sugar content in cubes/teaspoons/packets with health-related warning text), or (4) health pictorial warning (image of possible health consequences of overconsuming SSBs with health-related warning text).

MAIN OUTCOME MEASURES

Outcomes included participants' beverage choice for their child and perceptions of beverages, their assigned labels, and warning policies.

RESULTS

Proportionally fewer participants chose a SSB in the sugar pictorial warning condition (-13.4 percentage points; 95% CI= -21.6 to -0.1 percentage points; p=0.007) and in the health pictorial warning condition (-14.7 percentage points; 95% CI= -22.8 to -0.1 percentage points; p=0.004) compared to the control. Sugar pictorial warnings led to more accurate added-sugar content estimates than all conditions and greater label trust and support for sugar-sweetened beverage warning policies than health pictorial warnings.

CONCLUSIONS

SSB warning policies may be most effective if they mandate images of beverages' added sugar content accompanied by warning text.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT03648138.

Nutritional quality of snacks and beverages sold through vending machines in a large Hispanic-serving urban college campus in the United States: A cross-sectional study

Students from nutritionally-vulnerable neighborhoods face dietary challenges through built environment of college vending machines. In this cross-sectional study, snacks and beverages sold in vending machines for a 4-week period in a Bronx-based Hispanic-serving college were recorded. Nutritional information was recorded from nutrition labels. Proportion of low- and high-sodium foods, "smart snacks" with a limit of 200 kcal and 200 mg of sodium, and foods with added sugar were recorded. Snacks had significantly higher calories and sodium per serving (227 kcal, 208 mg) than beverages (132 kcal, 90 mg) (t-test, p < 0.001). Almost a third of the snacks (32%) qualified as "smart snacks" for calories and 62% qualified as "smart snacks" for sodium. Beverages contained less than half the number of ingredients as snacks. About 53% of beverages and almost 60% of snacks listed sugar among the first five ingredients. Results underscore the need for colleges to promote less-processed entities with less added sugar.

The National Clinical Care Commission Report to Congress: Leveraging Federal Policies and Programs for Population-Level Diabetes Prevention and Control: Recommendations From the National Clinical Care Commission

The etiology of type 2 diabetes is rooted in a myriad of factors and exposures at individual, community, and societal levels, many of which also affect the control of type 1 and type 2 diabetes. Not only do such factors impact risk and treatment at the time of diagnosis but they also can accumulate biologically from preconception, in utero, and across the life course. These factors include inadequate nutritional quality, poor access to physical activity resources, chronic stress (e.g., adverse childhood experiences, racism, and poverty), and exposures to environmental toxins. The National Clinical Care Commission (NCCC) concluded that the diabetes epidemic cannot be treated solely as a biomedical problem but must also be treated as a societal problem that requires an all-of-government approach. The NCCC determined that it is critical to design, leverage, and coordinate federal policies and programs to foster social and environmental conditions that facilitate the prevention and treatment of diabetes. This article reviews the rationale, scientific evidence base, and content of the NCCC's population-wide recommendations that address food systems; consumption of water over sugar-sweetened beverages; food and beverage labeling; marketing and advertising; workplace, ambient, and built environments; and research. Recommendations relate to specific federal policies, programs, agencies, and departments, including the U.S. Department of Agriculture, the Food and Drug Administration, the Federal Trade Commission, the Department of Housing and Urban Development, the Environmental Protection Agency, and others. These population-level recommendations are transformative. By recommending health-in-all-policies and an equity-based approach to governance, the NCCC Report to Congress has the potential to contribute to meaningful change across the diabetes continuum and beyond. Adopting these recommendations could significantly reduce diabetes incidence, complications, costs, and inequities. Substantial political resolve will be needed to translate recommendations into policy. Engagement by diverse members of the diabetes stakeholder community will be critical to such efforts.

Effect of Front-of-Package Information, Fruit Imagery, and High-Added Sugar Warning Labels on Parent Beverage Choices for Children: A Randomized Clinical Trial

IMPORTANCE

Fruit drinks are widely consumed by young children, and many parents mistakenly believe that these drinks are healthy, potentially due to front-of-package claims and imagery. Research is needed on the influence of this marketing and how labeling regulations could change behavior.

OBJECTIVE

To assess the effects of a front-of-package 100% vitamin C claim, fruit imagery, percentage juice and teaspoons of added sugar disclosures, and high-added sugar warnings on parents' choices, knowledge, and perceptions of beverages.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial was conducted May to July 2021 as a single-exposure (no follow-up) online survey of primary caregivers of children ages 0 to 5 years throughout the US.

INTERVENTIONS

Participants were shown no-, low-, and high-added sugar beverages and asked to choose 1 for their child. Participants were randomized to see high-added sugar beverages with 1 of 7 front-of-package conditions: (1) claim and imagery (control); (2) no claim; (3) no imagery; (4) no claim or imagery; (5) claim, imagery, and percentage juice disclosure; (6) claim, imagery, and warning; or (7) claim, imagery, warning, and teaspoons of added sugar disclosure.

MAIN OUTCOMES AND MEASURES

Primary outcomes were type of beverage chosen (eg, high-added sugar beverage) and resulting calories and added sugar (in grams). Secondary outcomes were fruit drink knowledge (added sugar and percent juice) and perceptions.

RESULTS

There were 5005 participants included in the final analysis (mean [SD] age, 31.5 [8.3] years; 3587 female participants [71.7%]), including 714 participants in group 1, 717 participants in group 2, 710 participants in group 3, 717 participants in group 4, 708 participants in group 5, 729 participants in group 6, and 710 participants in group 7. Compared with participants in the control group, who had a mean (standard error [SE]) of 9.4 (0.5) g of added sugar and 81.9 (1.6) kcal in chosen beverages, only participants who saw warnings with teaspoons of added sugar disclosures had significantly reduced added sugar (-1.3 g; 95% CI, -2.6 to -0.1 g [-14.2%; 95% CI, -26.7% to -1.8%]; P = .04) and calories (-5.3 kcal; 95% CI, -9.8 to -0.9 kcal [-6.5%; 95% CI, -11.8% to -1.3%]; P = .02) in selected beverages. In warning conditions (ie, 6 and 7) compared with the control group (mean [SE] 41.0% [1.8%]), the proportion of participants choosing high-added sugar beverages was significantly reduced, by 5.5 percentage points (95% CI, 0.5 to 10.5 percentage points [13.4%; 95% CI, 1.2% to 25.6%]; P = .03) and 6.4 percentage points (95% CI, 1.4 to 11.4 percentage points [15.6%; 95% CI, 3.3% to 27.8%]; P = .01), respectively. The no claim or imagery condition (4) significantly reduced the proportion of parents choosing high-added sugar beverages (-7.6 percentage points; 95% CI, -12.6 to -2.6 percentage points [-18.4%; 95% CI, -30.6% to -6.3%]; P = .003). Percentage juice disclosures did not affect beverage choice.

CONCLUSIONS AND RELEVANCE

These findings suggest that added sugar warnings and prohibitions of front-of-package claims and imagery may reduce parents' purchases of high-added sugar beverages for their young children but that percentage juice disclosures may not change behavior.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04811690.

Perceived effectiveness of added-sugar warning label designs for U.S. restaurant menus: An online randomized controlled trial

Added-sugar consumption in the U.S. exceeds recommended limits. Policymakers are considering requiring restaurants to use menu warning labels to indicate items high in added sugar. We sought to determine whether icon-only and icon-plus-text added-sugar menu labels were (1) perceived as more effective at potentially reducing consumption of items high in added sugar and (2) increased knowledge of menu items' added-sugar content relative to control labels, and if effects differed by label design. A national sample of U.S. adults (n = 1327) participated in an online randomized experiment. Participants viewed menu items with either a control label, 1 of 6 icon-only labels, or 1 of 18 icon-plus-text labels with 3 text variations. For their assigned label, participants provided ratings of perceived message effectiveness (a validated scale of a message's potential to change behavior). Participants were also asked to classify menu items by their added-sugar content. The icon-only and icon-plus-text labels were perceived as more effective than the control label (means: 3.7 and 3.7 vs. 3.1, respectively, on a 5-point scale; p < 0.001). The icon-only and icon-plus-text groups each correctly classified 71% of menu items by added-sugar content vs. 56% in the control group (p < 0.001). All icons and text variations were perceived as similarly effective. In conclusion, relative to a control label, icon-only and icon-plus-text added-sugar menu labels were perceived as effective and helped consumers identify items high in added sugar. Menu warning labels may be a promising strategy for reducing added-sugar consumption from restaurants, but research on behavioral effects in real-world settings is needed. Clinical Trials Identifier:NCT04637412.

Text Messages to Curb Sugar-Sweetened Beverage Consumption among Pregnant Women and Mothers: A Mobile Health Randomized Controlled Trial

Racial, ethnic, and socioeconomic disparities in childhood obesity in the United States (U.S.) originate in early life. Maternal sugar-sweetened beverage (SSB) consumption is an early life risk factor for later offspring obesity. The goal of this study was to test the effects of policy-relevant messages delivered by text messages mobile devices (mHealth) on maternal SSB consumption. In this three-arm 1-month randomized controlled trial (RCT), pregnant women or mothers of infants in predominantly Hispanic/Latino New York City neighborhoods were randomized to receive one of three text message sets: graphic beverage health warning labels, beverage sugar content information, or attention control. The main outcome was change in maternal self-reporting of average daily SSB consumption from baseline to one month. Among 262 participants, maternal SSB consumption declined over the 1-month period in all three arms. No intervention effect was detected in primary analyses. In sensitivity analyses accounting for outliers, graphic health warning labels reduced maternal SSB consumption by 28 kcal daily (95% CI: −56, −1). In this mHealth RCT among pregnant women and mothers of infants, graphic health warning labels and beverage sugar content information did not reduce maternal SSB consumption.

Developing sugar-sweetened beverage warning labels for young adults

OBJECTIVE

There is a lack of qualitative research developing sugar-sweetened beverage (SSB) warning labels with their intended end users. We sought to identify promising SSB warning elements for improving label effectiveness and for future testing in policy and institutional settings.

DESIGN

Mixed methods design using ten focus groups, a design task and a survey. The design task was used to generate ideas for an icon that would dissuade SSB consumption. The survey and focus group guide assessed participant perceptions of SSB warning label mock-ups of text (loss frame, gain frame and loss frame with attribution), colour and icon options.

SETTING

Three large public universities in California from February to March 2018.

PARTICIPANTS

Young adult SSB consumers (n 86) enrolled in one of three diverse California public universities.

RESULTS

Participants perceived the following elements as most effective for reducing SSB consumption: loss-frame text with attribution to a credible source, yellow and red colour for label background and an image or icon to accompany the text. Preferred images included sugar near or inside of an SSB, intuitive shapes like a triangle with exclamation mark or octagon and a visual indicator of SSB sugar content compared with recommended limits. Support was high for using SSB warning labels in university cafeterias and on bottles/cans.

CONCLUSIONS

Loss-frame text with a credible source, yellow or red label colour and icons could potentially enhance effectiveness of SSB warning labels and warrant further testing.