Literature review: Reducing the rate of SSBs consumption
Table of Contents
1. Introduction. 3
2. History of sugar sweeteners. 3
3. Sugar-sweetened beverages in America. 4
4. Correlation between sugar-sweetened beverages and obesity. 6
5. Reducing the rate of SSBs consumption. 7
5.1 Moderate taxation of sugar sweetened beverages. 8
5.2 Extreme tax on SSBs. 9
6. Media influence in SBBs consumption. 10
7. Banning of SSBs in schools. 14
8. Participation of beverage manufacturers. 14
9. Conclusion. 15
The available statistics on the consumption of caloric sweeteners indicates that between 1977 and 19996, the consumption of SSBs increased by 22% while between 1994 and 1996 the consumption increased by 30% (John & Chad, 2012). Currently, the most common source of the added sugar is non-diet soft drinks which account for half of the total added sugars in the American diet. Soft drink includes products as fruit drinks, lemonade and iced tea. Beside soft drinks, fruit drinks and fruitades are equally common especially in children and young children. The literature review focuses on the potential that can be used to reduce the rate of SSBs consumption, in the American context.
According to Apovian (2004) sugar derived from sugar cane was first developed in India and New Guinea and then the concept spread to Europe and Americas. Sugarcane was brought to the Americas and the Caribbean Islands by the Christopher Columbus. At the time, sugar was a very precious commodity, but afterwards mass production, increased its availability to the public. Today, sugar is a common ingredient in foods and drinks. Before introduction of sugar in diet, people normally depended on starch-based alternatives such as barley, wheat, oats, and rye. High-fructose corn syrup was introduced in the American market in 1970s and is preferred to normal sugar due to its long shelf life and is used in soft drinks, fruit punches, pastries and processed foods. According to Apovian (2004) both sugar and high fructose corn syrup have increased calories intake among the Americans population by 30% over the pat 40 years. With increased consumption of sugar, researchers have started becoming wary of its effects on peoples’ lives.
Sugar-sweetened beverages (SSBs) contain added sugar, high-fructose corn syrup and caloric sweeteners. They have become prevalent in America, where they are found to provide the general population with empty-calories besides being a major contributor to the current obesity epidemic. According to Babey, Wolstein and Goldstein (2013) for the pasts 50 years consumption of Sugar Sweetened Beverage has increased by 500% and the rate of consumption of SSBs in children is higher than that of milk. The available statistics suggest that SSBs account for 10-15% of total daily calories in children. Given the negative effects of Sugar Sweetened Beverage in children past efforts have bee taken by organizations such as the American Heart Association and Clinton Foundation to remove sweetened products in schools and replacing them with lower-calorie drinks.
Looking globally, the consumption of SSBs has been on the rise. In Mexico, the rise in the consumption of the SBBs has forced the government to take serious interventions while in China, India, Vietnam, and South Asian countries positive consumption trajectories have been reported. Incidences of obesity vary according to many factors including age, gender, education, and geographic distribution. In this regard, obesity menace is likely to affect elderly patients and thus consumption of sugar-sweetened beverages for members of this group should be discouraged. On the other hand, women have higher obesity rates than men. This means that adults, especially women should limit their daily SSBs consumption because they are more likely to gain weight than men. The level of family income also determines the level of SSBs consumption and ultimately the risk of obesity. In this regard, person from poor backgrounds are more predisposed to using sugar-sweetened beverages and hence are more susceptible to becoming overweight and obese. Babey, wolstein and Goldstein (2013) attribute this outcome to the fact that persons from poor backgrounds have low education and food knowledge, compared to their counterparts from high income families.
The available literature has investigated the prevalence of SSBs consumption in the society. Data released by the World Health Organization indicates that more one billion adults are overweight with a BMI of more ≥25 while 300 million people are obese with a BMI of ≥ 30. In the U.S. about 130 million are obese, and indication that the country accounts for a huge proportion of obesity cases in the world. These trends are worrying given that obesity is associated with negative outcomes such as hypertension, cardiovascular diseases, diabetes, prostrate cancer and depression. A study conducted by Ogden and Carrol (proposal) indicates that in America is obese and suggests that increased consumption of SSBs is likely to increase the already high obesity rates. The high levels of obesity in the country negatively impacts on the resources available. Already, the U.S. government spends more than $147 billion for the treatment of obesity-related ailments and this account for almost 10% of the total health care expenditure. At the same time, obesity is associated with lost of productivity costs. This ie because obese employees are more likely to miss work more that health works due to health-related problems and work for less hours. The employers are affected by the obesity menace as they are forced to pay higher in premium for employees diagnosed with obesity. A recent study conducted by John and Chad (2012) provides us with worrying statistics which illustrate the gravity of the obesity menace. According to John and Chad (2012) obesity-related ailments account for a fifth of the national health expenditures and while another one conducted by Rappange, Brouwer, Hoogenveen and Baal (2009) suggest that life-time drug expenditures for the obese persons is higher than for the healthy ones. This comprehensive study further concluded that obesity prevention significantly reduces drug expenditures and this one of the ways in which the government can be able to reduce the increasing health-care expenditure.
There are many studies that have examined the associations between consumption of SSBs and risk of diabetes. Schulze et al. (2004) used a sample of 116,671 women aged between 22-44 to examine the relation between SSBs consumption and weight change. Follow up studies were carried out between 1991 and 1999, and Schulze et al. (2004) concluded that there is a positive relation between SSBs consumption and weight gain and incidences of obesity. On the other hand, Vasanti, Mathias and Fran (2007) conducted a systematic review to investigate the effects of SSBs consumption on the health of the consumers. The systematic review included fifteen cross-sectional studies, all of which confirmed the positive association between consumption of SSBs and body weight gain, and risk of obesity. The studies involved in this systematic review all had strong methodologies and underwent a strict selection criterion. In addition, all the studies have large sample population, thus allowing the researchers to obtain conclusive evidence. The effects of the SSBs are also captured in a study by Dubois, Framer, Girard and Peterson (2007). In the study, a sample population of 1,944 schools going children was used and the data was collected through qualitative methods and then a multivariate regression analysis was conducted. As expected, the study conduced that regular SSBs consumption puts young children at a higher risk for obesity. The study challenge parents to limit the number of SSBs they give to their children. Research evidence for reducing SSBs in children is again given by Bellisle and Drewnowski (2007) in a study who sample population was aged between 2 and 5 years. Bellisle and Drewnowski (2007) evaluated the longitudinal and cross-sectional relationships between SSBs consumption and weight gain and found out children in this age bracket should decrease SSBs consumption for healthy living.
While the available studies have established a positive association between SSBs consumption and obesity, a few have examined the biological mechanisms leading to weigh gain. Bellisle and Drewnowski (2007) believe that SSBs lead to decreased satiety and incomplete compensatory reduction in energy intake in the subsequent meals. On the other hand, sucrose, and high-fructose corn syrups, lead to high dietary glacemic load and hence a higher risk for diabetes mellitus type 2 and cardiovascular diseases. The available literature has also found out that SSBs promotes accumulation of intra-abdominal adiposity and other unintended consequences. To prevent the high risk for obesity, the American Hearty Association recommends a daily intake of 100-5150 kcal and other alternatives such as consumption of water. Beside obesity, consumption sugar-sweetened beverages are associated with multiple obesity-related co morbidities such as hypertension, and cardiovascular diastase. Experts believe that increased calorie intake, not only leads to hypertension and also stroke, heart failure and myocardial infraction.
It is apparent that there is strong epidemiologic and clinical evidence linking SSBs and increased risk of obesity and obesity-related co-morbidities. From the above section, it is also apparent that there is need to provide school children with proper diet with low calories. This fact is exemplified by Babey, wolstein and Goldtsein (2013) in an article titled, still bubbling: California adolescents drinking more soda and other sugar-sweetened beverages. In this study, which was conducted in California, Babey, wolstein and Goldstein (2013 found out that consumption of SSBs in adolescents and children is still unacceptably high and SSBs are inferior compared to solid foods because they are associated with decreased intake of nutritious and more healthy foods. The study further found out that social and environmental factors are contributing to the increased consumption of SSBs. The article offers helpful suggestions such as educating children and parents about the health effects of SSBs. Despite these findings, it is apparent that there is limited literature on the interventions that can be used to reduce the higher obesity rates. This literature review, seeks to feel gaps by critically examining some of the potential measures that could prove helpful.
5.1 Moderate taxation of sugar sweetened beverages
Brownell et al. (2009) gives us irrefutable evidence on the adverse effects of sugar-sweetened beverages and then goes ahead to propose a tax system that could promote good nutrition and the national government to recover the additional healthcare costs associated with their consumption. According to Brownwell et al. (2009) an appropriate tax system has a potential of reducing the intake of beverages and this conclusion is based on the fact that changes in relative prices of foods and beverages will lead to changes in how much people consume. In this regard, Brownell et al. (2009) observes that a 10% increase in prices of sugar-sweetened beverages will translate to a 11% reduction in the consumption rate while Apovian (2004) argues that a 10% increase in the price of fast food, is associated with a 6% reduction in adolescent obesity. At the same time, researchers have established that an increase in SSB prices could increase consumption of healthier beverages such as milk and tea. Ultimately, increased consumption of healthier diets will reduce the prevalence of overweight among adults and children.
At the moment, most of the states only levy a sales tax on SSBs products and this situation can be improved on by placing an excise tax of 1% per ounce for beverages. Alternatively as Brownell et al. (2009) suggests the government could levy an excise tax on SSBs that exceed a threshold of grams of added caloric sweetener. The extra revenue generated could then be used to run obesity-prevention programs. While this idea could be appropriate, it could be prove inadequate as obesity-related prevention programs should be multipronged rather than increasing taxes on SSBs only.
Although research indicates that modest taxation on SSBs products could lead to a reduction in obesity levels, some studies tend to differ. A study by Powell, Chriqui, and Chaloupka (2009) found no association between modest taxes and adolescent weight outcomes. Just to illustrate this point, it is well acknowledged that in most states, SSBs attract higher sales tax, than other food products at 5.2%. However, despite this higher tax relative to other products in the same category, the level of consumption of SSBs is still high. The results of this study are reinforced by Kim (2009) who argues that modest taxes may not be result in a relative change in SSBs consumption. The results of these two studies, suggests that the government the needs to use stricter tax regimes in order to achieve tangible results as far as reduction of obesity in the society is concerned.
The limited research available shows that moderate taxation may not be effective in obesity prevention. These findings suggest that maybe states and government should consider levying extremely high taxes, either through excise tax to increase sales tax. The effectiveness of such a strategy is discussed in an article titled, 20% tax on sugary drinks would help cut obesity researchers say. In this article, medical researchers from the Academy of Medical Royal Colleges support a high tax on coca-cola, Pepsi, Fanta and other sugar-sweetened products. While supporting this move, researchers associate the 20% tax increase with a 1 % reduction in obesity cases. Those who are most likely to benefit from this strategy are those aged between 16 and29 while the government would be able to realize higher revenue. The additional revenue would be used to subsidize the prices of nutritional foods such as fruits and vegetable. Already countries such as Hungary, Finland and France have introduced high taxes on SSBs. While the information contained in this article is important, the information it contains is not supported by hard data.
It seems manufacturers do not support the proposal to levy SSBs high taxes as they would loose profitability due to high customer churn rate. To examine the likely impact of charging high taxes rather than modest prices, Maria et al. (2013) conducted a systematic review. In the study, Maria et al. (2013) used research articles from credible databases published between January 2000 and January 2013. Majority of the articles satisfied the selection criteria and showed that higher taxes on SSBs would translate to a decrease in BMI and the prevalence of overweight and obesity.
The effectiveness of high taxation on SSBs is revisited in an article titled, taxation prevention and as a treatment for obesity: the case of sugar-sweetened beverages. The article supports the introduction of high taxes on nutrient-poor products in order to nudge the customers towards healthier feeds. Novak and Brownell (2011) are disappointed that currently, the level of taxation on SSBs is very low, to affect consumer behavior. According to Novak and Brownell (2011) tax reduction of 20% would lead to an average weight reduction of 3.8 pounds per year for adults. In addition, this level of taxation would result in a 30% to 33% reduction of obesity incidences in the country. From these results, it is apparent that the obesity epidemic in the country can only be resolved through introduction of high taxes and not moderate taxes. However, the strategy is unlikely to work due to the stiff opposition from the players in the beverage industry.
One of the powerful tools that have been used to market the SBBs is the media. The importance of the media to businesses is well investigated by Berger (2004). Advertising is an important part of the American society and is a useful tool in portraying a particular attribute about a product or a service. Whether print or non-print, advertisements are supposed to attract consumers within a particular segment, and then stimulate action that results in the actual purchase of products and services being advertised. SSBs manufacturers will go to any extent to sell their products and services. As of now, consumers are becoming increasingly careful of what they eat, and some of manufacturers are advertising their products to be healthy while they are not. This whole issue is related to the concept of branding and the use of marketing mix elements, which are important in conveying the right information to the buyers to help them make healthier food choices. According to Chrysochou (2010) most of the media tools that are used during branding of foods are primary communication channels and secondary channels. At the same time, the manufacturers use innovative strategies such as celebrity endorsements to endear their products to the consumers.
One of fundamental questions concerning the consumption of the SSBs is why consumers continue using the products, knowing too well their harmful effects. The answer to this question can be found in the article titled, communication on food, health and nutrition. According to Gram, De la Ville, Le Roux, Boireau and Rampnoux (2010) the beverage industry uses a lot resource in marketing their products. One of the common strategies used by the large companies such Coca-Cola is differentiation of their products. Currently, the company offers a wide range of products to suit the needs of different customers’ needs. The company has sizable market share in the fruit drinks, energy drinks, sports drinks, iced tea and vitamin-enriched water markets.
To increase the penetration of their products, the players in the food industry depends on the market segmentation. Through micro-segmentation they are able to fulfill particular characteristics of the target population and according to Gram, De la Ville, Le Roux, Boireau and Rampnoux (2010) the young population is segmented by gender, lifestyles and values. The other concept, as discussed by Gram, De la Ville, Le Roux, Boireau and Rampnoux (2010) is the use marketing positioning concept which allows consumers to identify products or bands. The players in the beverage industry depend on the functional and symbolic dimensions to sell different products and services to their wide clientele. The symbolic dimension is particularly important among the young people as they are sensitive to particular characteristics and values unlike the consumers in the other age groups. The marketing mix used by the beverages industries vary according to the type of the product being sold. In this regard, the soft drinks market targets the young consumers and to increase the consumption of products and service in this segment, the players in the food industry use multi-platform marketing. Likewise, energy drinks target the young population, and to increase their consumption, the food industry primarily uses the celebrity endorsement strategy. To promote the consumption of the soft drinks beverage manufacturers uses the similar strategy of celebrity endorsements.
While media can be used to popularize the use of SSBs it can also be used to influence good consumer choices. The effectiveness of the media in the reduction of SSBs consumption is well discussed in the article titled, developing media interventions to reduce household sugar-sweetened beverage consumption. In this article Jordan, Piotrowski, Bleakley and Mallya (2012) used a sample drawn from Philadelphia and the researchers used an integrative model to determine the most cost-effective message content. Jordan, Piotrowski, Bleakley and Mallya (2012) determined that effective messages should highlight concerns such as child weight gain in order to increase the intention to reduce SSBs.
Beside the use of mainstream media, studies have investigated whether social media could be used in the promotion of health behaviors in children and school going children. It is well acknowledged that consumers have huge access to the internet and social media tools and these social networks can be used to disseminate information to the most affected persons in the society. The results of 8 randomized trials support the use of internet-base interventions especially among children and adolescents who are heavy consumers of SSBs. The results of these studies indicate that social interventions can effectively be used to promote positive behaviors such as weight loss, reduction of the BMI, physical activity and natural diet intake. However, these studies used small samples, and the length of follow-ups was short hence the need to conduct further research using larger samples.
An alternative to using social media tools would be to regulate initiate federal regulations to limit consumption of SSBs. Only recently, the Council of the Better Business Bureau established guidelines to direct child-related advertisements. The use of federal regulation to regulate children-related advertisements is reinforced by Wiecha, Peterson, Ludwig, Kim, Sobol, and Gortmaker (2006) in a study conducted among 6th and 7th grade studies. According to Wiecha, Peterson, Ludwig, Kim, Sobol, and Gortmaker (2006) high rates of TV viewing translates to higher total calories, while low rates of TV viewing leads to lower total calories intake among the adolescents. The other available research on this issue concur that television marketing influences the short-term consumption of children aged between 2 and 11 years. Wiecha, Peterson, Ludwig, Kim, Sobol, and Gortmaker (2006) proposed a model to examine the likely effect if SSBs advertisements were banned, and found out that it would reduce prevalence of obesity by 2% and BMI by 0.38 kg/m2. Based on these results, some of the schools have taken deliberate measures to limit TV exposure to children and a good example is the State of Maine School Advertising Policy which prohibits brand-specific advertising in school building. Likewise in San Francisco, the Commercial Free School Act prohibits adverting of commercial products including SSBs within San Francisco Unified School District.
For long, school children have had unfettered access to SSBs but for the past few years some states and school districts have initiated policies to restrict these younger users. However, while such policies could limit access to SSBs they do not reduce their consumption. These findings are supported by a study performed by researchers led by Taber, Chriqui, Powell, and Chaloupka (2012). In this study, 6,900 students were surveyed in 40 different states and concluded state and school police are not associated with a reduction in consumption sweetened beverages (Taber, Chriqui, Powell, & Chaloupka, 2012). The results of these finding suggest that maybe schools and the authorities should rather use education programs to inform potential consumers about the negative effects of the SSBs. The effects of the school education programs are well documented in the study by James, Thomas, Cavan and Kerr (2004). In the study, use of school education programs led to a significant decrease in SSBs consumption and other positive outcomes. These results are replicated in a different study performed in sample drawn from the Midwestern families. Use of public education programs was found to increase consumption of health foods while reducing consumption of SSBs (Lawrence, Boyle, Craypo, & Samuels, 2009).
While the available literature has focused on the role of the media and taxation, in the reduction of SSBs consumption, few studies have investigated the potential role of the food industry in reducing consumption of unhealthy drinks especially among the youths and the adolescents. Despite the health concerns resulting from the use of SSBs, companies in the food industry have not take sincere steps to promote healthy behaviors among the consumers. Lack of commitment from the SSBs raises the issue of whether they can be able to cut calories in their products while maintaining profits. This issue is revisited by Kleiman and Popkin (2012) where they observe that some of the 16 biggest food and beverage companies in America have come together with the goal of reducing the number of calories consumed by the Americans. This partnerships, is intended to cut down calories consumption by 1.5 trillion by 2015. As Kleiman and Popkin (2012) observes, as a result of this initiative, positive effects are already being experienced, but more empirical studies need to be conducted to investigate the validity of these results.
For the past few decades the consumption of sugar-sweetened beverages has increased considerably and is one of the major contributors to the current obesity epidemic. The intake of sugary diet has also been linked to obesity-related co-morbidities such as hypertension, stroke, heart failure and myocardial infraction. Due to the strong epidemiologic and clinical evidence linking SSBs with adverse health outcomes, the available research has proposed introduction of higher taxes or decreasing the relative costs of more healthful beverage alternatives. The available literature seems to suggest that higher taxation is more effective than moderate taxation. Other alternatives are: regulating child-directed advertisements, increasing the participation of the beverage manufacturers and initiation of education programs. However, there is consensus on whether limiting access of SSBs in school could reduce obesity, and other related outcomes.
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