What's the best way to stop us guzzling fizzy drinks?

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Researchers are trialling lots of different ways to influence us to buy or drink fewer sugary drinks - but what actually works? The latest Cochrane Review evaluates several different interventions and found that price increases can decrease sales of sugary drinks in supermarkets and restaurants - as did subsidies and promotion of healthier drinks. However, the reviewers specifically didn't look into sugar taxes as they plan to evaluate them separately. They also investigated labelling, drink options in schools, home-based interventions and substitution of drinks in fast-food chains and found all to be somewhat successful - though some changes had only limited evidence backing them up.

Journal/conference: Cochrane Database of Systematic Reviews

DOI: 10.1002/14651858.CD012292.pub2.


Media Release

From: Cochrane

New Cochrane Review assesses evidence on different ways to reduce consumption of sugary drinks

Consumption of sugary drinks is considered to be a key driver behind the global obesity epidemic, and is linked with tooth decay, diabetes and heart disease. Many public health bodies including the World Health Organization (WHO) have called upon governments, the food and drink industry, educational institutions, places of work and civil society to support healthier beverage choices.

This new Cochrane Review summarizes evidence from research studies testing different ways of reducing consumption of sugary drinks at a population level. A team of researchers from Germany and the UK looked at the results from 58 studies that assessed a range of approaches and strategies aimed at changing the physical or social environment where people consume or buy sugary drinks. The studies were done in a variety of settings, including schools, cafes, restaurants, homes, and retail outlets. The studies assessed a wide range of different approaches to reduce consumption such as labelling and pricing of sugar sweetened drinks and healthy alternatives. They also looked at broader policy initiatives such as community-based campaigns to encourage healthier choices. The studies were conducted in 19 different countries from North and South America, Australasia and Europe and South East Asia.

Within the broad categories of interventions studied, (labelling, nutrition standards, price increases and subsidies, home-based interventions, interventions aimed at the whole food supply, retail and food services, and intersectoral approaches such as food benefit programs and trade and investment policies), the certainty of the evidence for specific measures ranged from very low to moderate.

The review authors identified a number of measures which the available scientific evidence indicates reduces the amount of sugary drinks people drink. These measures included:

·  Labels that are easy to understand, such as ‘traffic-light’ labels, and labels that rate the healthiness of beverages with stars or numbers.

·  Limits to the availability of sugary drinks in schools.

·  Price increases on sugary drinks in restaurants, stores and leisure centres.

·  Children’s menus in chain restaurants which include healthier beverages instead of sugary drinks as the default.

·  Promotion and better placement of healthier beverages in supermarkets.

·  Government food benefits (e.g. food stamps) which cannot be used to purchase sugary drinks.

·  Community campaigns focused on supporting healthy beverage choices.

·  Measures that improve the availability of low-calorie beverages at home, e.g. through home deliveries of bottled water and diet beverages.

The Cochrane authors also found evidence that improved availability of drinking water and diet beverages at home can help people lose weight. There are also other measures which may influence how much sugary drinks people drink, but for these the available evidence is less certain.

Past research has shown that health education and taxation of sugar-sweetened beverages can also help to reduce their consumption, but these approaches were not examined in the current review. Taxation of sugary drinks, unprocessed sugar and sugar-added foods will be examined in two future Cochrane Reviews.

Review author Hans Hauner, Professor of Nutritional Medicine at Technical University Munich, Germany, and a world-leading expert in the field, commented: “Rates of obesity and diabetes are rising globally, and this trend will not be reversed without broad and effective action. Governments and industry in particular must do their part to make the healthy choice the easy choice for consumers. This review highlights key measures that can help to accomplish this.”

Review author Eva Rehfuess, Professor of Public Health and Health Services Research at LMU Munich, Germany, adds: “This review highlights essential building blocks for a comprehensive strategy to support healthy beverage choices for the whole population. However, we need to do more work to understand what works best in specific settings, such as schools and workplaces, for people of different socio-economic and cultural backgrounds, and in countries at different levels of economic development. This would help us to improve existing approaches further. Policy-makers and practitioners who implement such measures should therefore cooperate with researchers to allow for high-quality evaluations.”

Review lead author Peter von Philipsborn, Research Associate at LMU Munich, Germany, said: “Sugary drinks are a global problem, and middle-income countries such as South Africa, Mexico and Brazil are particularly affected. The measures highlighted in this review should be considered by policy-makers worldwide.”

This Cochrane Review from Cochrane Public Health was conducted by researchers affiliated with the Institute of Medical Information Processing, Biometry and Epidemiology at the Pettenkofer School of Public Health at the LMU Munich, the Technical University Munich, and University College London.


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Expert Reaction

These comments have been collated by the Science Media Centre to provide a variety of expert perspectives on this issue. Feel free to use these quotes in your stories. Views expressed are the personal opinions of the experts named. They do not represent the views of the SMC or any other organisation unless specifically stated.

Associate Professor Pawel Olszewski, Physiology lecturer, University of Waikato

Based on the findings, I would emphasise that the evidence that supports the effectiveness of environmental interventions to lower sugary drink consumption is of low-to-moderate certainty. Long-term effects of these interventions and their suitability for large-scale implementation are yet to be determined.

Last updated: 14 Jun 2019 10:44am
Declared conflicts of interest:
None declared.
Dr Bodo Lang, Head of Marketing at The University of Auckland

Global obesity rates and related illnesses are increasing at an alarming rate. The resulting health costs at the societal level and the negative impact on individual lives is enormous. Sugary drinks have been shown to contribute towards this health crisis. 

"Therefore, having scientific evidence that assesses the effectiveness of different interventions is of paramount importance. The results of the study are highly useful for a variety of organisations but most importantly for central and local governments who can affect systemic change in today’s complex food environments.

"What makes the findings of this study particularly useful is the fact that it is based on multiple other studies, thereby avoiding the biases and limitations of any single study. 

"Importantly, the study indicates that a number of interventions are effective across different cultures and geographic regions. This indicates the universal impact that these interventions appear to have on consumers’ consumption of sugary drinks. 

"What makes the study particularly important is the fact that consumption of sugary drinks in many markets is at an all-time high. Specifically, many markets show a decline in consumption of traditional soft drinks (e.g. colas or sodas) but this decline has been more than compensated for by the rapid increase in consumption of flavoured milks, sports drinks, energy drinks and other types of beverages. Therefore, the need to reduce the consumption of sugary beverages is now greater than ever.

Last updated: 14 Jun 2019 10:43am
Declared conflicts of interest:
None declared.
Dr Eric Crampton, Chief Economist at The New Zealand Initiative

The Cochrane Review provides an important synthesis of the evidence regarding non-tax interventions aimed at reducing consumption of sugar-sweetened beverages [SSBs].

“The review found that many often-recommended measures have little evidentiary base, with certainty of evidence rated as very low. Interventions in this category included measures like healthier vending machines in workplaces and schools, restrictions on the number of stores selling sugar-sweetened beverages, urban planning restrictions on new fast-food outlets, and menu-board calorie labelling. No studies were found that might provide basis for restrictions on advertising.

“Some measures showed promise, with a moderate certainty of evidence established across numerous studies.

“Improved access to low-calorie beverages in the home environment reduced SSB consumption, but many included studies focused on places without reliable access to clean drinking water. Regular home delivery of free non-SSB drinks across broad swathes of the population seems unlikely to pass any reasonable cost-benefit assessment, and especially in places where piped water is of reasonable quality.”

“Restrictions placed on purchases funded through food benefit programmes reduced sugar-sweetened beverage consumption, and could be implemented in New Zealand by adding sugar-sweetened beverages to the list of prohibited purchases on Work and Income Payment Cards. But the administrative costs may not be trivial, and the imposition on low-income households who enjoy soda occasionally should not be ignored.

“Small prizes for selecting healthier beverages in primary school cafeterias showed some promise.

“While price increases in individual targeted stores showed reduced sales of sugar-sweetened beverages in those particular venues, the surveyed studies in that area do not look at overall consumption; people could easily have shifted to purchasing from outlets where prices had not been hiked.

“And while the review authors tentatively suggested a somewhat broader set of interventions may prove effective, they also warned that their confidence in the likely effects is low to moderate. Rather than providing evidence for policy change, we should view the report as suggesting measures potentially worth trialling within an appropriate experimental framework designed to improve the evidence base.

“Where the evidence base presented for any substantial effect of interventions is moderate at best, even without being evaluated as part of a broader cost-benefit assessment that weighs implementation costs and costs to consumers, we should be highly sceptical of any calls for strong intervention based on this report. It should rather temper our enthusiasm for large-scale measures likely to impose substantial cost for rather less certain benefit. Pilot studies and trials of some of the more promising interventions may be warranted.

Last updated: 14 Jun 2019 10:42am
Declared conflicts of interest:
The New Zealand Initiative is an independent think-tank funded by the membership subscriptions of many of New Zealand’s most prominent companies, including supermarkets and food industry companies. The breadth of the Initiative’s membership base across a wide range of industries helps ensure its independence.

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