Gradual reduction of free sugars in beverages on sale by implementing the beverage checklist as a public health strategy

Gradual reduction of free sugars in beverages on sale by implementing the beverage checklist as a... Abstract Background Sugar-sweetened beverages (SSBs) are a major source of free sugar intake and contribute to obesity and obesity-related diseases. Therefore, we analyzed the effect of a gradual sugar reduction strategy within the so-called ‘beverage checklist’ on free sugar content in beverages on sale in Austria. Methods From 2010 until 2017, data on the amount of free sugar of sweetened beverages (sweetened with sugars, fruit juice and artificial sweeteners) with 0.20–0.75l serving sizes in all main supermarkets and from industry was collected. These data were published annually as the beverage checklist, which displays beverages on sale in Austria. The checklist aims to encourage beverage production with a free sugar content of ≤7.4 g/100 ml and no artificial sweeteners. Results Free sugar content in the total supply decreased significantly [7.53 (2.86) vs. 6.75 (2.79) g/100 ml; 10.4%; P < 0.001] over time and also in those for which follow-up data were available until 2017 (n = 100) [7.55 (2.46) vs. 7.28 (2.44) g/100 ml; 3.5%; P < 0.001]. The percentage of beverages fulfilling the guiding criteria increased by 12.8% (P < 0.001) and of those containing sweeteners decreased by 13.3% (after 2012; P = 0.034). Conclusions This public health strategy, conducted by a small non-profit organization, showed a reduction in the mean free sugar content by working with the industry to voluntarily reformulate beverages. More beverages with less added sugar were brought to the market, which implies healthier choices. The challenge now is to further engage the industry and also policy makers to achieve a greater reduction in the future. Introduction Several studies have indicated a positive association between the consumption of sugar-sweetened beverages (SSBs) and body weight measures in both children and adults,1,2 as well as type 2 diabetes mellitus3 and dental caries.4,5 SSBs are a contributory factor to the rising levels of childhood and adult obesity in many countries worldwide.6 They are the largest source of free sugars in children and the second largest in adults.7 Moreover, sales of SSBs are increasing worldwide,8 and there is heavy marketing in low- and middle-income countries.9 In a recent analysis of SSB sales, trends around the world have indicated that the four regions with the highest consumption are North America, Latin America, Australasia and Western Europe, with Germany, the Netherlands, Slovakia and Austria in the ranking of the top ten countries in 2014.10 Regarding European adolescents, the HELENA study showed that 30% of the energy, as provided by beverages, came from SSBs.11 A modelling study estimated 184 000 deaths per year to be attributable to SSB consumption, of which 133 000 came from diabetes mellitus, 45 000 from cardiovascular disease and 6450 from cancers.12 From a public health point of view, approaches to reducing SSB intake and free sugar content are warranted to improve public health. One successful and feasible example of a voluntary gradual reduction strategy is the UK voluntary salt reduction programme, which has encouraged the food industry to gradually decrease the quantity of salt added to processed food.13 Sweetened foods and beverages might be more worrying to the health of children and adolescents compared to adults, as evidence suggests that exposure during early development can affect choices and preferences which persist throughout life.14 Therefore, healthier choices need to be brought into the market. A strategy for the gradual and stepwise reduction of free sugars in SSBs, without the use of artificial sweeteners, is predicted to lead to an effective and sustainable reduction of energy intake and to reduce the prevalence of overweight, obesity and type 2 diabetes mellitus in the population.7 In general, consumers are often uninformed about the free sugar content in products they regularly buy. Therefore, in Austria, a so-called ‘beverage checklist’ was implemented, which displays beverages on sale and detailed information regarding the free sugar content, inter alia, of a product can be obtained. The beverage checklist is available to the public for free via online search and mobile app. The beverage checklist was initially introduced for schools and, in particular, as a guideline for the vending machine and school cafeteria providers. It is noteworthy that using the beverage checklist as a sugar reduction strategy by encouraging the industry to decrease the free sugar content in SSBs is voluntary. Moreover, there has been little effort made in evaluating the free sugar content of SSBs in Europe, except for the UK,15 and also in reformulating the beverages by the industry. Therefore, the objectives of this study were to analyze the effect of implementing the gradual free sugar reduction strategy—the beverage checklist with guiding criteria—on the free sugar content in beverages on sale in Austria, the percentage of beverages containing sweeteners and fulfilment of the criteria from 2010 until 2017. Methods The beverage checklist and its development In 2010, the beverage checklist was implemented in Austria by the SIPCAN scientific association (Special Institute for Preventive Cardiology and Nutrition), which is an independent and non-profit organization with the focus on public health nutrition. The beverage checklist is aimed at consumers, as well as stakeholders, professionals and the beverage industry. The beverage checklist includes sweetened beverages and, as an addendum (additional information), specific isotonic sports drinks (which are specifically advertised for sports and with various additives such as minerals, etc.) and energy drinks. The Codex Alimentarius Austriacus (Austrian food codex) defines energy drinks as non-alcoholic drinks which contain at least 11 g carbohydrates or sugars and 150 mg/l caffeine.16 Two guiding criteria were implemented in 2010 to provide guidance to the consumer with regard to beverages that contain low or moderate levels of free sugar content and to encourage the industry to gradually decrease the amount of free sugars added to beverages: (i) free sugar content ≤7.4 g free sugars/100 ml; and (ii) no artificial or natural intense sweeteners (e.g. Stevia). If the beverage fulfilled these two criteria, it was displayed in the so-called ‘positive list’. The cut-off of 7.4 g free sugars/100 ml was based on the World Health Organization (WHO) recommendation of <10% of daily energy intake from added sugars.17 Considering our main target group of adolescents and assuming an average of 2450 kcal daily energy intake (13–14 years18), a total of 60 g free sugars/day was calculated. Furthermore, considering 0.5 l of SSB, half of the maximum daily recommendation is 30 g/500 ml, which is 6 g free sugars/100 ml. This halving is in accordance with the WHO guideline from 2015 (<5% of energy intake/day).19 Both adolescents and the whole population need to get accustomed to the reduced free sugar content in beverages, and the beverage industry also needs time to adapt. Therefore, we decided to implement a tolerance range of 25% for 2010, which is a maximum of 7.4 g free sugars/100 ml. Indeed, the purpose of this tolerance range is to further reduce it in the future. The second criterion on excluding artificial and natural intense sweeteners was based on several studies at that time indicating that intake of foods or fluids containing non-nutritive sweeteners were accompanied by increased food intake, weight gain, accumulation of body fat and weaker caloric compensation, compared to consumption of foods and fluids containing glucose.20 In addition, this dissociation between the sweet taste cues and the caloric consequences could lead to a reduction in the ability of sweet tastes to induce physiological responses that help to regulate energy balance.20 Moreover, at that time, there was also evidence suggesting that artificial sweeteners can increase the risk of cancers.21 Both guiding criteria were reviewed by the Austrian Federal Ministry of Health, the Austrian Agency for Health and Food Safety, the Austrian Society for Nutrition and the Austrian Federal Ministry of Education. The beverage checklist was incorporated in all guidelines published by the Ministry of Health regarding the catering sector, e.g. school cafeterias.22 Data collection Data on the free sugar content in beverages on sale in Austria were collected. This study was designed as a comprehensive survey of all beverages available in a snapshot in time of every year from 2010 until 2017, using one large outlet in at least three out of nine federal states per each of the four main supermarket chains (Rewe, Spar, Lidl, Hofer), which together hold 88% of the grocery market share in Austria.23 In addition, since 2012, all known beverage producers were sent a list of their products with the data obtained from the supermarket research and were asked to check their products on free sugar content, etc. and add their new products. In 2012, the response rate of the industry was 33% and in 2017 it was 75%. For each beverage, we collected the following information: company name, product name, beverage category (beverages, sports and energy drinks), caffeine (yes/no), artificial sweeteners (yes/no), fruit content (%), organic (yes/no) and free sugar content (g/100 ml). All data were double-checked after entry and were based on data provided on the available beverage packaging labels in store on the dates of collection and the information provided by the food and beverage industry. We categorized the (total) free sugar content of SSBs on sale in Austria by colour-coded labels, based on the guidelines of the UK Department of Health and the Food Standards Agency24: low (green) ≤2.5 g/100 ml; medium (orange) >2.5–11.25 g/100 ml and high (red) >11.25 g/100 ml.24 Inclusion/exclusion criteria We included beverages between 0.20 and 0.75 l in PET (polyethylene terephthalate) and carton bottles, as some brands sell the same formulation in different serving sizes and sweetened with free sugars (including unsweetened fruit juice) and artificial sweeteners. However, no 100% fruit juice was included in the checklist as this type of fluid belongs to the ‘vegetables, pulses and fruit’ food group, according to the Austrian Food Pyramid25 and also no mineral water as it is not sweetened with free sugars or artificial sweeteners. Statistical analysis The results are expressed as mean [standard error or 95% confidence interval (CI)] for continuous variables and as percentages for categorical variables. Beverages with and without sweeteners were included in the statistical analysis. Sports and energy drinks were analyzed separately as these types of beverages only serve as an addendum in the beverage checklist. In order to test for normal distribution, a visual test (histograms and box plots) was used and the Kolmogorov–Smirnov test was also applied. Statistical significance tests such as t-tests, Mann–Whitney U-tests or Chi2 tests were applied to assess the differences between baseline (2010) and the following years (2011–17). Mixed model analysis with random effects is a useful method for modelling and analysing longitudinal data and repeated measurements. As the occurrence of missing data in longitudinal data is probable, analysis of unbalanced designs and missing data is one of the advantages of this model. Another advantage is to be able to examine the differences in the dependent variable units in different times.26 Therefore, we used repeated-measures analysis of covariance (ANCOVA) using random error (linear mixed model) to assess the changes in free sugar content over time by using different covariance structure models, as appropriate. In addition, we also adjusted for fruit content (%). Moreover, a post-hoc analysis with Bonferroni correction was used. Estimates of the percentage of beverages containing artificial sweeteners and of beverages fulfilling the guiding criteria over time were calculated using generalized estimating equations (GEE) with a logit link function for binary outcomes and unstructured covariance matrices. With this approach, we examined the effect of time as the repeated factor and usage of sweeteners (yes/no) or fulfilling criteria (yes/no) as dependent variable, adjusted for fruit content (%). All statistical analyses were performed with IBM® SPSS® Statistics for Windows, Version 24 software (IBM Corporation, Armonk, New York, U.S.). P-values <0.05 were considered statistically significant and all tests were two-sided. Results The number of SSBs (2010: 320 vs. 2017: 477; figure 1) and energy drinks (2010: 29 vs. 2017: 76) in the checklist increased but sports drinks did not increase (2010: 38 vs. 2017: 31). Sports and energy drinks are included as an addendum in the beverage checklist and are not the main focus of the beverage checklist. Therefore, these types of beverages can be considered as a self-contained group within the SSBs. Therefore, sports and energy drinks are not included in the further statistical analyses of this article, to ensure that we examine a homogenous group of SSBs. Figure 1 View largeDownload slide Free sugar content (g/100 ml) and number of SSBs with (A) and without sweeteners (B) in the beverage checklist over time. Note: Error bars represent standard error; * P-value <0.05 by using t-test comparing baseline (2010) with following years Figure 1 View largeDownload slide Free sugar content (g/100 ml) and number of SSBs with (A) and without sweeteners (B) in the beverage checklist over time. Note: Error bars represent standard error; * P-value <0.05 by using t-test comparing baseline (2010) with following years Free sugar content in total supply The following analyses represent the changing market supply over the last 7 years. Figure 1 shows the mean reduction in free sugar content over time in the total supply of SSBs with and without sweeteners (all beverages on sale and excluding sports and energy drinks) and the increasing number of SSBs on sale in Austria. This absolute mean reduction in SSBs on sale without sweeteners corresponds to a 10.4% continuous reduction when comparing the baseline free sugar content from 2010 with the level in 2017 (P < 0.001). In contrast, compared to the baseline, the free sugar content of beverages with sweeteners decreased up until 2013 (P = 0.963) and then increased by 31.3% in 2015 (P = 0.047) and by 9.7% in 2017 (P = 0.519). The total amount of free sugars in an average SSB without sweeteners was 37.7 (SD 14.3) g per 500 ml serving size in 2010 while it was 33.8 (SD 14.0) g per 500 ml (P < 0.001) in 2017. As expected, the energy content (kcal) (using a 500 ml serving size of an average SSB without sweeteners) also decreased significantly from 154 (SD 59) kcal to 138 (SD 57) kcal in 2017 (P < 0.001). When consuming 500 ml of an average SSB without sweeteners, this accounted for 7.7 (2.9)% of the total energy intake (2000 kcal) in 2010 and for 6.9 (2.9)% in 2017 (P < 0.001). Taking the WHO recommendations for sugar consumption of <10% (strong recommendation) or <5% (conditional recommendation) of total calories per day19 into account and considering 500 ml as the serving size, there was a significant increase of beverages fulfilling these recommendations: the percentage of SSBs representing <10% of energy intake increased from 73% in 2010 to 84% in 2017 (P < 0.001) and those representing <5% of energy intake from 17% to 27% (P = 0.041). By analysing the colour-coded labels based on the guidelines of the Food Standards Agency,24 there was an increase in SSBs without sweeteners of low free sugar content (green) by 4% and of medium free sugar content (orange) by 1%. Furthermore, the category of high free sugar content (red) decreased by 5% (table 1). Table 1 Number and percentage of beverages (without sweeteners) using the colour-coded labels of low (green), medium (orange) and high (red) free sugar content, based on the Food Standards Agency guidelines,24 from 2010 until 2017 Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  a Chi2 test. Table 1 Number and percentage of beverages (without sweeteners) using the colour-coded labels of low (green), medium (orange) and high (red) free sugar content, based on the Food Standards Agency guidelines,24 from 2010 until 2017 Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  a Chi2 test. In addition, by using the linear mixed model, there was a significant reduction of the mean free sugar content in SSBs without sweeteners, adjusted for fruit content. The mean free sugar content changed significantly from 7.33 g/100 ml (95% CI 7.12, 7.55) to 7.03 g/100 ml (95% CI 6.84, 7.23), which is a mean reduction of 4.1% when comparing the baseline free sugar content from 2010 with the level in 2017 (P < 0.001). Free sugar content of SSBs follow-up When comparing only beverages which were included in the 2010 data and those for which follow-up data were available until 2017 (n = 100 beverages), we could observe a significant reduction of the free sugar content over the observation period, adjusted for fruit content. The mean free sugar content decreased from 7.55 g/100 ml (95% CI 6.84, 7.87) to 7.28 g/100 ml (95%CI 7.05, 8.08) from 2010 until 2017 (figure 2), which is a mean reduction of 3.5% (P = 0.002). Figure 2 View largeDownload slide Mean reduction of free sugar content (g/100 ml) by using follow-up data of 100 beverages without sweeteners over time. Note: Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%); Error bars represent standard error; * P-value <0.05, comparing baseline (2010) with following years Figure 2 View largeDownload slide Mean reduction of free sugar content (g/100 ml) by using follow-up data of 100 beverages without sweeteners over time. Note: Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%); Error bars represent standard error; * P-value <0.05, comparing baseline (2010) with following years Beverages fulfilling the guiding criteria Table 2 presents the change of free sugar content over time divided by two groups, i.e. beverages not fulfilling the guiding criteria and those fulfilling them (≤7.4 g free sugars/100 ml and no artificial sweeteners). In both groups, the free sugar content reduced significantly over time (P < 0.001) and there was a group difference (P < 0.001) with a group and time interaction (P < 0.001). In beverages not fulfilling the criteria, the mean free sugar reduction was 5.4% (P < 0.001) and in those fulfilling the criteria it was 2.5% compared to baseline in 2010 (P = 1.000). Moreover, the percentage of beverages fulfilling the guiding criteria significantly increased over the observation period of 7 years (table 2), which is an increase of 12.8% (P < 0.001). Table 2 Change of mean free sugar content (g/100 ml) in two groups of beverages (beverages fulfilling the guiding criteria of the beverage checklist and those not fulfilling it), as well as the percentage of beverages fulfilling the criteria from 2010 until 2017 Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Note: Data are presented as mean (95% confidence interval) and percentage (95% confidence interval). a ≤7.4 g free sugars/100 ml (1st criteria) and beverages containing no artificial sweeteners (2nd criteria). b >7.4 g free sugars/100 ml and beverages containing artificial sweeteners. c Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%). d Generalized estimating equations (GEE) with a logit link function for binary outcomes, adjusted for fruit content (%). Table 2 Change of mean free sugar content (g/100 ml) in two groups of beverages (beverages fulfilling the guiding criteria of the beverage checklist and those not fulfilling it), as well as the percentage of beverages fulfilling the criteria from 2010 until 2017 Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Note: Data are presented as mean (95% confidence interval) and percentage (95% confidence interval). a ≤7.4 g free sugars/100 ml (1st criteria) and beverages containing no artificial sweeteners (2nd criteria). b >7.4 g free sugars/100 ml and beverages containing artificial sweeteners. c Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%). d Generalized estimating equations (GEE) with a logit link function for binary outcomes, adjusted for fruit content (%). Changes in usage of artificial sweeteners The percentage of beverages containing artificial sweeteners first increased from 2010 (16.6%) until 2012 (20.2%) and then continuously decreased until 2017 (13.3%; P = 0.034). By comparing the data of 2012 with the data of 2017, the reduction of the percentage of beverages containing sweeteners was 7.0% (P = 0.014). Discussion After the implementation of the SIPCAN beverage checklist in 2010, the free sugar content in SSBs on sale in Austria and in beverages followed up from 2010 onwards decreased significantly until 2017. The percentage of beverages fulfilling the guiding criteria increased over the observation period, while the frequency of beverages containing sweeteners decreased after 2012. The effect of this strategy was that more new and reformulated beverages with less added sugars were brought to the market, which implies healthier choices for consumers. High energy intake from energy-dense foods and, here especially, beverages might be the key contributor to the high obesity prevalence worldwide, mainly due to changes in the food environment towards an obesogenic environment. Therefore, an alternative strategy for obesity control is to encourage slight changes in diet and physical activity to primarily prevent further weight gain.27 Accordingly, the obesity prevalence could be first stabilized and then, over time, decreased gradually. With this so-called ‘small-changes approach’ advocated by Hill27 and others, it might be possible to decrease obesity rates as it is intended to help people make conscious small changes in lifestyle behaviours. Furthermore, in the private sector, e.g. the food and beverage industry, it might be possible to gradually reduce some of the environmental factors which contribute to excessive energy intake. Accordingly, while it is necessary for individuals to make changes to their personal habits, it is also important for the food and beverage industry to make reductions too.28 These strategies are also known as the so-called ‘upstream’ approaches, which are applied at the macro-level, focusing on targeting changes at environmental and policy levels.28 There is the opportunity in using these approaches to bring different stakeholders together. However, without changing the obesogenic environment, effective behavioural interventions might not be sustainable in the long term.27 One successful and feasible example of a gradual reduction strategy or upstream approach is the UK voluntary salt reduction programme implemented by the Food Standards Agency (FSA), a non-ministerial government department. This programme was aimed at getting the food industry to gradually decrease the quantity of salt added to processed food over the past decade.13 Incremental salt reduction targets were set, with a clear timeframe for the food industry to reach them, and the population salt intake was reduced by 15%.13 The reduction in salt intake was likely associated with decreases in the population blood pressure.29 Much of this reduction has been achieved through partnership with industry to set voluntary reformulation targets.13 In addition to this, reducing salt intake through voluntary reformulation and increasing public awareness has been a highly cost-effective policy option. Voluntary recommendations also allowed the FSA to advocate for the highest reduction possible, instead of setting only maximum targets, which would have been the case if these were set in legislation.30 Regarding free sugars, a modelling study revealed that an incremental reduction in free sugars added to SSBs without the use of artificial sweeteners is predicted to reduce the prevalence of overweight, obesity and type 2 diabetes.7 These findings suggest that this innovative strategy for the gradual and stepwise reduction of free sugars might lead to an effective and sustainable reduction of energy intake and body weight in the population.7 Our gradual free sugar reduction strategy in Austria was carried out by a small non-profit and non-governmental organization. In 2012, the beverage industry started responding to the beverage checklist. Furthermore, by 2014, there was a higher media presence, and in 2016, a mobile app was developed with regard to the public health strategy. We believe that by continuing our work, it will be possible to get the industry to voluntarily reformulate their products, and voluntary agreements might be able to push the industry to go beyond ‘business as usual’. Furthermore, successful voluntary agreements require early involvement of a wide range of stakeholders for pledge targets to be meaningful.31 However, the greatest risk involved in a voluntary approach is designing a scheme which is too complex and causes businesses to disengage with the process or, in contrast, establishing targets which are easily achievable but fail to deliver the policy objectives.30 There is also evidence that various countries have already established and implemented approaches focusing on the reduction of SSB intake by, for example, limiting their availability, increasing marketing price, raising public awareness through education programmes by media and school, tax policies and clear labelling.7 Action is needed across all policy domains––the food environment, food system and behaviour change communication––as each plays an important role in influencing what we consume.32 Studies have now shown that the purchase of SSBs is decreasing in countries following the introduction of taxes on SSBs, e.g. in Mexico,33 with a greater reduction in 2015 compared to 2014. The absolute and relative reductions in Mexico were the highest among households at lower socioeconomic levels.33 However, there is, to date, no evidence that the tax on SSBs in Mexico has had any impact on levels of obesity. Finally, we believe that voluntary gradual free sugar reduction by the beverage industry to tackle obesity and non-communicable diseases will be part of the solution with the greatest public health impact. Changes in consumers’ preferences regarding flavour and sweet taste might also be possible and could occur after reformulation. However, reformulation strategies are expected to take time to implement and will happen gradually. Moreover, we think that in addition to the beverage checklist to inform consumer choice, we do also need even more political pressure to ensure compliance to reformulation or free sugar reduction. This could be reinforced by media campaigns or by guidelines to the catering sector, e.g. school cafeterias, which was also part of our public health strategy. Mandatory reformulation might thus be more effective than voluntary reformulation. Reducing the free sugar content in sugary drinks appears to be effective and, thus, is a ripe target for regulation. In the coming years, we will gradually reduce the guiding criterion to a maximum of 6 g free sugars/100 ml. Finally, multi-component interventions appear to be more effective than single interventions.34 Limitations The study has several limitations. Firstly, the beverage checklist’s guiding criterion of a free sugar content of ≤7.4 g free sugars/100 ml is based on the WHO recommendation.17 The calculation of this cut-off is based on adolescents’ total energy expenditure, on the consideration of 0.5 l SSB and of a tolerance range of 25%. This cut-off value differs from other recommendations, such as the guidelines of the UK Department of Health and the FSA24 and/or the announced UK SSB tax.35 However, adolescents, our initial target group, and the whole population need to get accustomed to the reduced free sugar content in beverages and the beverage industry also needs time to adapt. Therefore, a tolerance range of 25% seemed appropriate. However, we intend to reduce this tolerance range in the near future. The second limitation in this study is that it might be possible that some beverages were unintentionally excluded, as the beverage checklist is a comprehensive survey of all beverages available in a snapshot in time of every year, using one large outlet in at least three out of nine federal states per each of the four main supermarket chains, which together hold 88% of the grocery market share in Austria. Due to this fact, since 2012, all known beverage producers were asked to add their products to the beverage checklist. However, at the beginning of this approach, the response rate of the industry was low, but then increased until 2017. The third limitation might be that specific isotonic sports and energy drinks serve only as an addendum to the beverage checklist, and this addendum cannot be considered as a complete list of these specific beverages on sale in Austria. Furthermore, these types of beverages were not the initial focus of the beverage checklist, and according to the Austrian Association of Beverage Manufacturers, the percentage of the market was only 11% in 2016.30 However, to the best of our knowledge, this is the first study assessing free sugar content over a certain time period and giving implications for further public health initiatives to tackle obesity. Conclusions In conclusion, the beverage checklist, as a public health strategy, reduced the free sugar content in SSBs by working with the industry to reformulate beverages with less free sugars on a voluntary basis. Hence, more beverages with less added sugars were brought to the market, which implies healthier choices for consumers and the whole population. The challenge now is to further engage the industry and also policy makers to achieve a greater reduction in the future, and also to implement a consumer awareness campaign. Acknowledgement The authors would also like to thank Mark Ackerley for the professional proofreading. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflicts of interest: None declared. Key points We investigated the free sugar content in SSBs over a certain time period and suggest implications for further public health initiatives to tackle obesity. The free sugar content in SSBs decreased due to working with the industry, as they brought more beverages with less added sugars to the market, which implies healthier choices for the population. As this gradual sugar reduction strategy was carried out by a small non-profit organization, an even greater reduction could be achieved in the future by bringing it to the policy-making level. References 1 Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr  2013; 98: 1084– 102. Google Scholar CrossRef Search ADS PubMed  2 Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ  2012; 346: e7492. Google Scholar CrossRef Search ADS PubMed  3 Greenwood DC, Threapleton DE, Evans CE, et al.   Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose-response meta-analysis of prospective studies. Br J Nutr  2014; 112: 725– 34. Google Scholar CrossRef Search ADS PubMed  4 Marshall TA, Levy SM, Broffitt B, et al.   Dental caries and beverage consumption in young children. Pediatrics  2003; 112: e184– 91. Google Scholar CrossRef Search ADS PubMed  5 Wilder JR, Kaste LM, Handler A, et al.   The association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Public Health Dent  2016; 76: 76– 84. Google Scholar CrossRef Search ADS PubMed  6 Lobstein T. Available at: http://www.who.int/elena/titles/commentary/ssbs_childhood_obesity/en/ (5 May 2017, date last accessed). 7 Ma Y, He FJ, Yin Y, et al.   Gradual reduction of sugar in soft drinks without substitution as a strategy to reduce overweight, obesity, and type 2 diabetes: a modelling study. Lancet Diabetes Endocrinol  2016; 4: 105– 14. Google Scholar CrossRef Search ADS PubMed  8 Singh GM, Micha R, Khatibzadeh S, et al.   Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: a systematic assessment of beverage intake in 187 countries. PLoS One  2015; 10: e0124845. Google Scholar CrossRef Search ADS PubMed  9 World Health Organization. Available at: http://www.who.int/elena/bbc/ssbs_adult_weight/en/ (15 January 2016, date last accessed). 10 Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol  2016; 4: 174– 86. Google Scholar CrossRef Search ADS PubMed  11 Duffey KJ, Huybrechts I, Mouratidou T, et al.   Beverage consumption among European adolescents in the HELENA study. Eur J Clin Nutr  2012; 66: 244– 52. Google Scholar CrossRef Search ADS PubMed  12 Singh GM, Micha R, Khatibzadeh S, et al.   Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in 2010. Circulation  2015; 132: 639– 66. Google Scholar CrossRef Search ADS PubMed  13 He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens  2014; 28: 345– 52. Google Scholar CrossRef Search ADS PubMed  14 Mennella JA. Ontogeny of taste preferences: basic biology and implications for health. Am J Clin Nutr  2014; 99: 704S– 11S. Google Scholar CrossRef Search ADS PubMed  15 Hashem KM, He FJ, Jenner KH, MacGregor GA. Cross-sectional survey of the amount of free sugars and calories in carbonated sugar-sweetened beverages on sale in the UK. BMJ Open  2016; 6: e010874. Google Scholar CrossRef Search ADS PubMed  16 Codex Alimentarius Austriacus (IV. Edition). Available at: http://www.lebensmittelbuch.at/erfrischungsgetraenke/energie-getraenke-energy-drinks/ (16 January 2018, date last accessed). 17 World Health Organization (WHO). Diet, Nutrition and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation . Geneva: World Health Organization (WHO), 2003. Contract No.: No. 916. 18 German Nutrition Society (DGE), Austrian Nutrition Society (ÖGE), Swiss Nutrition Society (SGE). Energie. D-A-CH-Referenzwerte für die Nährstoffzufuhr. Neustadt a. d. Weinstraß: Neuer Umschau Buchverlag, 2008. 19 World Health Organization. Sugars Intake for Adults and Children. Guideline . Geneva: World Health Organization, 2015: 49. 20 Swithers SE, Martin AA, Davidson TL. High-intensity sweeteners and energy balance. Physiol Behav  2010; 100: 55– 62. Google Scholar CrossRef Search ADS PubMed  21 Bosetti C, Gallus S, Talamini R, et al.   Artificial sweeteners and the risk of gastric, pancreatic, and endometrial cancers in Italy. Cancer Epidemiol Biomarkers Prev  2009; 18: 2235– 8. Google Scholar CrossRef Search ADS   22 Austrian Federal Ministry of Health. Available at: https://www.bmgf.gv.at/cms/home/attachments/6/4/0/CH1047/CMS1313558884746/leitlinie_schulbuffet_20150619.pdf (12 June 2017, date last accessed). 23 Cash Pocket. Available at: http://www.cash.at/uploads/media/CASH_Pocket_0215.pdf (8 May 2017, date last accessed). 24 Department of Health, Food Standards Agency. Available at: https://www.food.gov.uk/sites/default/files/multimedia/pdfs/pdf-ni/fop-guidance.pdf (15 May 2017, date last accessed). 25 Austrian Agency for Health and Food Safety (AGES). Available at: https://www.ages.at/en/topics/nutrition/the-austrian-food-pyramid/# (16 January 2018, date last accessed). 26 Kazemi E, Hosseini SM, Bahrampour A, et al.   Predicting of trend of hemoglobin a1c in type 2 diabetes: a longitudinal linear mixed model. Int J Prev Med  2014; 5: 1274– 80. Google Scholar PubMed  27 Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr  2009; 89: 477– 84. Google Scholar CrossRef Search ADS PubMed  28 Buttriss JL, Welch AA, Kearney JM, Lanham-New SA. In: Sons JW, editor. Public Health Nutrition . UK: Wiley-Blackwell, 2017: 456. 29 He FJ, Pombo-Rodrigues S, Macgregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open  2014; 4: e004549. Google Scholar CrossRef Search ADS PubMed  30 Austrian Association of Beverage Manufacturers. Available at: http://getraenkeverband.at/limonade/zahlen-und-daten/1641-oesterreichischer-limonadenmarkt-2016.html (16 January 2018, date last accessed). 31 Bryden A, Petticrew M, Mays N, et al.   Voluntary agreements between government and business–a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy  2013; 110: 186– 97. Google Scholar CrossRef Search ADS PubMed  32 World Cancer Research Fund International. Available at: http://www.wcrf.org/sites/default/files/Curbing-Global-Sugar-Consumption.pdf (31 May 2017, date last accessed). 33 Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ  2016; 352: h6704. Google Scholar CrossRef Search ADS PubMed  34 Hyseni L, Atkinson M, Bromley H, et al.   The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review. Eur J Clin Nutr  2017; 71: 694– 711. Google Scholar CrossRef Search ADS PubMed  35 UK government. Available at: https://www.gov.uk/government/publications/soft-drinks-industry-levy/soft-drinks-industry-levy (16 January 2018, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png The European Journal of Public Health Oxford University Press

Gradual reduction of free sugars in beverages on sale by implementing the beverage checklist as a public health strategy

Loading next page...
 
/lp/ou_press/gradual-reduction-of-free-sugars-in-beverages-on-sale-by-implementing-iWVwxVQ9pE
Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
ISSN
1101-1262
eISSN
1464-360X
D.O.I.
10.1093/eurpub/cky039
Publisher site
See Article on Publisher Site

Abstract

Abstract Background Sugar-sweetened beverages (SSBs) are a major source of free sugar intake and contribute to obesity and obesity-related diseases. Therefore, we analyzed the effect of a gradual sugar reduction strategy within the so-called ‘beverage checklist’ on free sugar content in beverages on sale in Austria. Methods From 2010 until 2017, data on the amount of free sugar of sweetened beverages (sweetened with sugars, fruit juice and artificial sweeteners) with 0.20–0.75l serving sizes in all main supermarkets and from industry was collected. These data were published annually as the beverage checklist, which displays beverages on sale in Austria. The checklist aims to encourage beverage production with a free sugar content of ≤7.4 g/100 ml and no artificial sweeteners. Results Free sugar content in the total supply decreased significantly [7.53 (2.86) vs. 6.75 (2.79) g/100 ml; 10.4%; P < 0.001] over time and also in those for which follow-up data were available until 2017 (n = 100) [7.55 (2.46) vs. 7.28 (2.44) g/100 ml; 3.5%; P < 0.001]. The percentage of beverages fulfilling the guiding criteria increased by 12.8% (P < 0.001) and of those containing sweeteners decreased by 13.3% (after 2012; P = 0.034). Conclusions This public health strategy, conducted by a small non-profit organization, showed a reduction in the mean free sugar content by working with the industry to voluntarily reformulate beverages. More beverages with less added sugar were brought to the market, which implies healthier choices. The challenge now is to further engage the industry and also policy makers to achieve a greater reduction in the future. Introduction Several studies have indicated a positive association between the consumption of sugar-sweetened beverages (SSBs) and body weight measures in both children and adults,1,2 as well as type 2 diabetes mellitus3 and dental caries.4,5 SSBs are a contributory factor to the rising levels of childhood and adult obesity in many countries worldwide.6 They are the largest source of free sugars in children and the second largest in adults.7 Moreover, sales of SSBs are increasing worldwide,8 and there is heavy marketing in low- and middle-income countries.9 In a recent analysis of SSB sales, trends around the world have indicated that the four regions with the highest consumption are North America, Latin America, Australasia and Western Europe, with Germany, the Netherlands, Slovakia and Austria in the ranking of the top ten countries in 2014.10 Regarding European adolescents, the HELENA study showed that 30% of the energy, as provided by beverages, came from SSBs.11 A modelling study estimated 184 000 deaths per year to be attributable to SSB consumption, of which 133 000 came from diabetes mellitus, 45 000 from cardiovascular disease and 6450 from cancers.12 From a public health point of view, approaches to reducing SSB intake and free sugar content are warranted to improve public health. One successful and feasible example of a voluntary gradual reduction strategy is the UK voluntary salt reduction programme, which has encouraged the food industry to gradually decrease the quantity of salt added to processed food.13 Sweetened foods and beverages might be more worrying to the health of children and adolescents compared to adults, as evidence suggests that exposure during early development can affect choices and preferences which persist throughout life.14 Therefore, healthier choices need to be brought into the market. A strategy for the gradual and stepwise reduction of free sugars in SSBs, without the use of artificial sweeteners, is predicted to lead to an effective and sustainable reduction of energy intake and to reduce the prevalence of overweight, obesity and type 2 diabetes mellitus in the population.7 In general, consumers are often uninformed about the free sugar content in products they regularly buy. Therefore, in Austria, a so-called ‘beverage checklist’ was implemented, which displays beverages on sale and detailed information regarding the free sugar content, inter alia, of a product can be obtained. The beverage checklist is available to the public for free via online search and mobile app. The beverage checklist was initially introduced for schools and, in particular, as a guideline for the vending machine and school cafeteria providers. It is noteworthy that using the beverage checklist as a sugar reduction strategy by encouraging the industry to decrease the free sugar content in SSBs is voluntary. Moreover, there has been little effort made in evaluating the free sugar content of SSBs in Europe, except for the UK,15 and also in reformulating the beverages by the industry. Therefore, the objectives of this study were to analyze the effect of implementing the gradual free sugar reduction strategy—the beverage checklist with guiding criteria—on the free sugar content in beverages on sale in Austria, the percentage of beverages containing sweeteners and fulfilment of the criteria from 2010 until 2017. Methods The beverage checklist and its development In 2010, the beverage checklist was implemented in Austria by the SIPCAN scientific association (Special Institute for Preventive Cardiology and Nutrition), which is an independent and non-profit organization with the focus on public health nutrition. The beverage checklist is aimed at consumers, as well as stakeholders, professionals and the beverage industry. The beverage checklist includes sweetened beverages and, as an addendum (additional information), specific isotonic sports drinks (which are specifically advertised for sports and with various additives such as minerals, etc.) and energy drinks. The Codex Alimentarius Austriacus (Austrian food codex) defines energy drinks as non-alcoholic drinks which contain at least 11 g carbohydrates or sugars and 150 mg/l caffeine.16 Two guiding criteria were implemented in 2010 to provide guidance to the consumer with regard to beverages that contain low or moderate levels of free sugar content and to encourage the industry to gradually decrease the amount of free sugars added to beverages: (i) free sugar content ≤7.4 g free sugars/100 ml; and (ii) no artificial or natural intense sweeteners (e.g. Stevia). If the beverage fulfilled these two criteria, it was displayed in the so-called ‘positive list’. The cut-off of 7.4 g free sugars/100 ml was based on the World Health Organization (WHO) recommendation of <10% of daily energy intake from added sugars.17 Considering our main target group of adolescents and assuming an average of 2450 kcal daily energy intake (13–14 years18), a total of 60 g free sugars/day was calculated. Furthermore, considering 0.5 l of SSB, half of the maximum daily recommendation is 30 g/500 ml, which is 6 g free sugars/100 ml. This halving is in accordance with the WHO guideline from 2015 (<5% of energy intake/day).19 Both adolescents and the whole population need to get accustomed to the reduced free sugar content in beverages, and the beverage industry also needs time to adapt. Therefore, we decided to implement a tolerance range of 25% for 2010, which is a maximum of 7.4 g free sugars/100 ml. Indeed, the purpose of this tolerance range is to further reduce it in the future. The second criterion on excluding artificial and natural intense sweeteners was based on several studies at that time indicating that intake of foods or fluids containing non-nutritive sweeteners were accompanied by increased food intake, weight gain, accumulation of body fat and weaker caloric compensation, compared to consumption of foods and fluids containing glucose.20 In addition, this dissociation between the sweet taste cues and the caloric consequences could lead to a reduction in the ability of sweet tastes to induce physiological responses that help to regulate energy balance.20 Moreover, at that time, there was also evidence suggesting that artificial sweeteners can increase the risk of cancers.21 Both guiding criteria were reviewed by the Austrian Federal Ministry of Health, the Austrian Agency for Health and Food Safety, the Austrian Society for Nutrition and the Austrian Federal Ministry of Education. The beverage checklist was incorporated in all guidelines published by the Ministry of Health regarding the catering sector, e.g. school cafeterias.22 Data collection Data on the free sugar content in beverages on sale in Austria were collected. This study was designed as a comprehensive survey of all beverages available in a snapshot in time of every year from 2010 until 2017, using one large outlet in at least three out of nine federal states per each of the four main supermarket chains (Rewe, Spar, Lidl, Hofer), which together hold 88% of the grocery market share in Austria.23 In addition, since 2012, all known beverage producers were sent a list of their products with the data obtained from the supermarket research and were asked to check their products on free sugar content, etc. and add their new products. In 2012, the response rate of the industry was 33% and in 2017 it was 75%. For each beverage, we collected the following information: company name, product name, beverage category (beverages, sports and energy drinks), caffeine (yes/no), artificial sweeteners (yes/no), fruit content (%), organic (yes/no) and free sugar content (g/100 ml). All data were double-checked after entry and were based on data provided on the available beverage packaging labels in store on the dates of collection and the information provided by the food and beverage industry. We categorized the (total) free sugar content of SSBs on sale in Austria by colour-coded labels, based on the guidelines of the UK Department of Health and the Food Standards Agency24: low (green) ≤2.5 g/100 ml; medium (orange) >2.5–11.25 g/100 ml and high (red) >11.25 g/100 ml.24 Inclusion/exclusion criteria We included beverages between 0.20 and 0.75 l in PET (polyethylene terephthalate) and carton bottles, as some brands sell the same formulation in different serving sizes and sweetened with free sugars (including unsweetened fruit juice) and artificial sweeteners. However, no 100% fruit juice was included in the checklist as this type of fluid belongs to the ‘vegetables, pulses and fruit’ food group, according to the Austrian Food Pyramid25 and also no mineral water as it is not sweetened with free sugars or artificial sweeteners. Statistical analysis The results are expressed as mean [standard error or 95% confidence interval (CI)] for continuous variables and as percentages for categorical variables. Beverages with and without sweeteners were included in the statistical analysis. Sports and energy drinks were analyzed separately as these types of beverages only serve as an addendum in the beverage checklist. In order to test for normal distribution, a visual test (histograms and box plots) was used and the Kolmogorov–Smirnov test was also applied. Statistical significance tests such as t-tests, Mann–Whitney U-tests or Chi2 tests were applied to assess the differences between baseline (2010) and the following years (2011–17). Mixed model analysis with random effects is a useful method for modelling and analysing longitudinal data and repeated measurements. As the occurrence of missing data in longitudinal data is probable, analysis of unbalanced designs and missing data is one of the advantages of this model. Another advantage is to be able to examine the differences in the dependent variable units in different times.26 Therefore, we used repeated-measures analysis of covariance (ANCOVA) using random error (linear mixed model) to assess the changes in free sugar content over time by using different covariance structure models, as appropriate. In addition, we also adjusted for fruit content (%). Moreover, a post-hoc analysis with Bonferroni correction was used. Estimates of the percentage of beverages containing artificial sweeteners and of beverages fulfilling the guiding criteria over time were calculated using generalized estimating equations (GEE) with a logit link function for binary outcomes and unstructured covariance matrices. With this approach, we examined the effect of time as the repeated factor and usage of sweeteners (yes/no) or fulfilling criteria (yes/no) as dependent variable, adjusted for fruit content (%). All statistical analyses were performed with IBM® SPSS® Statistics for Windows, Version 24 software (IBM Corporation, Armonk, New York, U.S.). P-values <0.05 were considered statistically significant and all tests were two-sided. Results The number of SSBs (2010: 320 vs. 2017: 477; figure 1) and energy drinks (2010: 29 vs. 2017: 76) in the checklist increased but sports drinks did not increase (2010: 38 vs. 2017: 31). Sports and energy drinks are included as an addendum in the beverage checklist and are not the main focus of the beverage checklist. Therefore, these types of beverages can be considered as a self-contained group within the SSBs. Therefore, sports and energy drinks are not included in the further statistical analyses of this article, to ensure that we examine a homogenous group of SSBs. Figure 1 View largeDownload slide Free sugar content (g/100 ml) and number of SSBs with (A) and without sweeteners (B) in the beverage checklist over time. Note: Error bars represent standard error; * P-value <0.05 by using t-test comparing baseline (2010) with following years Figure 1 View largeDownload slide Free sugar content (g/100 ml) and number of SSBs with (A) and without sweeteners (B) in the beverage checklist over time. Note: Error bars represent standard error; * P-value <0.05 by using t-test comparing baseline (2010) with following years Free sugar content in total supply The following analyses represent the changing market supply over the last 7 years. Figure 1 shows the mean reduction in free sugar content over time in the total supply of SSBs with and without sweeteners (all beverages on sale and excluding sports and energy drinks) and the increasing number of SSBs on sale in Austria. This absolute mean reduction in SSBs on sale without sweeteners corresponds to a 10.4% continuous reduction when comparing the baseline free sugar content from 2010 with the level in 2017 (P < 0.001). In contrast, compared to the baseline, the free sugar content of beverages with sweeteners decreased up until 2013 (P = 0.963) and then increased by 31.3% in 2015 (P = 0.047) and by 9.7% in 2017 (P = 0.519). The total amount of free sugars in an average SSB without sweeteners was 37.7 (SD 14.3) g per 500 ml serving size in 2010 while it was 33.8 (SD 14.0) g per 500 ml (P < 0.001) in 2017. As expected, the energy content (kcal) (using a 500 ml serving size of an average SSB without sweeteners) also decreased significantly from 154 (SD 59) kcal to 138 (SD 57) kcal in 2017 (P < 0.001). When consuming 500 ml of an average SSB without sweeteners, this accounted for 7.7 (2.9)% of the total energy intake (2000 kcal) in 2010 and for 6.9 (2.9)% in 2017 (P < 0.001). Taking the WHO recommendations for sugar consumption of <10% (strong recommendation) or <5% (conditional recommendation) of total calories per day19 into account and considering 500 ml as the serving size, there was a significant increase of beverages fulfilling these recommendations: the percentage of SSBs representing <10% of energy intake increased from 73% in 2010 to 84% in 2017 (P < 0.001) and those representing <5% of energy intake from 17% to 27% (P = 0.041). By analysing the colour-coded labels based on the guidelines of the Food Standards Agency,24 there was an increase in SSBs without sweeteners of low free sugar content (green) by 4% and of medium free sugar content (orange) by 1%. Furthermore, the category of high free sugar content (red) decreased by 5% (table 1). Table 1 Number and percentage of beverages (without sweeteners) using the colour-coded labels of low (green), medium (orange) and high (red) free sugar content, based on the Food Standards Agency guidelines,24 from 2010 until 2017 Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  a Chi2 test. Table 1 Number and percentage of beverages (without sweeteners) using the colour-coded labels of low (green), medium (orange) and high (red) free sugar content, based on the Food Standards Agency guidelines,24 from 2010 until 2017 Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  Label  Low (green)   Medium (orange)   High (red)   P-valuea  n  %  n  %  n  %  2010  5  1.8  254  90.1  23  8.2  <0.001  2011  4  1.3  279  91.8  21  6.9  2012  4  1.5  252  92.6  16  5.9  2013  1  0.4  246  92.1  20  7.5  2014  4  1.0  366  94.8  16  4.1  2015  12  3.2  354  94.1  10  2.7  2016  25  5.2  436  91.4  16  3.4  2017  25  5.2  436  91.4  16  3.4  a Chi2 test. In addition, by using the linear mixed model, there was a significant reduction of the mean free sugar content in SSBs without sweeteners, adjusted for fruit content. The mean free sugar content changed significantly from 7.33 g/100 ml (95% CI 7.12, 7.55) to 7.03 g/100 ml (95% CI 6.84, 7.23), which is a mean reduction of 4.1% when comparing the baseline free sugar content from 2010 with the level in 2017 (P < 0.001). Free sugar content of SSBs follow-up When comparing only beverages which were included in the 2010 data and those for which follow-up data were available until 2017 (n = 100 beverages), we could observe a significant reduction of the free sugar content over the observation period, adjusted for fruit content. The mean free sugar content decreased from 7.55 g/100 ml (95% CI 6.84, 7.87) to 7.28 g/100 ml (95%CI 7.05, 8.08) from 2010 until 2017 (figure 2), which is a mean reduction of 3.5% (P = 0.002). Figure 2 View largeDownload slide Mean reduction of free sugar content (g/100 ml) by using follow-up data of 100 beverages without sweeteners over time. Note: Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%); Error bars represent standard error; * P-value <0.05, comparing baseline (2010) with following years Figure 2 View largeDownload slide Mean reduction of free sugar content (g/100 ml) by using follow-up data of 100 beverages without sweeteners over time. Note: Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%); Error bars represent standard error; * P-value <0.05, comparing baseline (2010) with following years Beverages fulfilling the guiding criteria Table 2 presents the change of free sugar content over time divided by two groups, i.e. beverages not fulfilling the guiding criteria and those fulfilling them (≤7.4 g free sugars/100 ml and no artificial sweeteners). In both groups, the free sugar content reduced significantly over time (P < 0.001) and there was a group difference (P < 0.001) with a group and time interaction (P < 0.001). In beverages not fulfilling the criteria, the mean free sugar reduction was 5.4% (P < 0.001) and in those fulfilling the criteria it was 2.5% compared to baseline in 2010 (P = 1.000). Moreover, the percentage of beverages fulfilling the guiding criteria significantly increased over the observation period of 7 years (table 2), which is an increase of 12.8% (P < 0.001). Table 2 Change of mean free sugar content (g/100 ml) in two groups of beverages (beverages fulfilling the guiding criteria of the beverage checklist and those not fulfilling it), as well as the percentage of beverages fulfilling the criteria from 2010 until 2017 Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Note: Data are presented as mean (95% confidence interval) and percentage (95% confidence interval). a ≤7.4 g free sugars/100 ml (1st criteria) and beverages containing no artificial sweeteners (2nd criteria). b >7.4 g free sugars/100 ml and beverages containing artificial sweeteners. c Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%). d Generalized estimating equations (GEE) with a logit link function for binary outcomes, adjusted for fruit content (%). Table 2 Change of mean free sugar content (g/100 ml) in two groups of beverages (beverages fulfilling the guiding criteria of the beverage checklist and those not fulfilling it), as well as the percentage of beverages fulfilling the criteria from 2010 until 2017 Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Free sugar content [g/100 ml]  2010  2011  2012  2013  2014  2015  2016  2017  P-valuesc   Time  Group  Group x time  Criteria fulfilleda  6.03  6  6.01  5.95  5.93  5.87  5.88  5.88  <0.001  <0.001  <0.001  (5.78, 6.28)  (5.78, 6.23)  (5.79, 6.23)  (5.72, 6.17)  (5.71, 6.14)  (5.67, 6.07)  (5.68, 6.07)  (5.68, 6.07)  Criteria not fulfilledb  7.26  7.27  7.23  7.2  7.1  6.87  6.86  6.86  (7.01, 7.5)  (7.05, 7.49)  (7.00, 7.45)  (6.97, 7.43)  (6.88, 7.31)  (6.67, 7.08)  (6.66, 7.06)  (6.66, 7.06)  Percentage of beverage [%]  2010  2011  2012  2013  2014  2015  2016  2017  P-valued  Criteria fulfilleda  43.3  47.5  52.6  53.8  55.6  54.8  56.1  56.1  0.001  –  –  (37.7, 49.1)  (42.1, 53)  (47.1, 58)  (48.1, 59.3)  (50.8, 60.3)  (49.7, 59.8)  (51.4, 60.7)  (51.4, 60.7)  Note: Data are presented as mean (95% confidence interval) and percentage (95% confidence interval). a ≤7.4 g free sugars/100 ml (1st criteria) and beverages containing no artificial sweeteners (2nd criteria). b >7.4 g free sugars/100 ml and beverages containing artificial sweeteners. c Repeated-measures analysis of variance and post-hoc analysis with Bonferroni correction, adjusted for fruit content (%). d Generalized estimating equations (GEE) with a logit link function for binary outcomes, adjusted for fruit content (%). Changes in usage of artificial sweeteners The percentage of beverages containing artificial sweeteners first increased from 2010 (16.6%) until 2012 (20.2%) and then continuously decreased until 2017 (13.3%; P = 0.034). By comparing the data of 2012 with the data of 2017, the reduction of the percentage of beverages containing sweeteners was 7.0% (P = 0.014). Discussion After the implementation of the SIPCAN beverage checklist in 2010, the free sugar content in SSBs on sale in Austria and in beverages followed up from 2010 onwards decreased significantly until 2017. The percentage of beverages fulfilling the guiding criteria increased over the observation period, while the frequency of beverages containing sweeteners decreased after 2012. The effect of this strategy was that more new and reformulated beverages with less added sugars were brought to the market, which implies healthier choices for consumers. High energy intake from energy-dense foods and, here especially, beverages might be the key contributor to the high obesity prevalence worldwide, mainly due to changes in the food environment towards an obesogenic environment. Therefore, an alternative strategy for obesity control is to encourage slight changes in diet and physical activity to primarily prevent further weight gain.27 Accordingly, the obesity prevalence could be first stabilized and then, over time, decreased gradually. With this so-called ‘small-changes approach’ advocated by Hill27 and others, it might be possible to decrease obesity rates as it is intended to help people make conscious small changes in lifestyle behaviours. Furthermore, in the private sector, e.g. the food and beverage industry, it might be possible to gradually reduce some of the environmental factors which contribute to excessive energy intake. Accordingly, while it is necessary for individuals to make changes to their personal habits, it is also important for the food and beverage industry to make reductions too.28 These strategies are also known as the so-called ‘upstream’ approaches, which are applied at the macro-level, focusing on targeting changes at environmental and policy levels.28 There is the opportunity in using these approaches to bring different stakeholders together. However, without changing the obesogenic environment, effective behavioural interventions might not be sustainable in the long term.27 One successful and feasible example of a gradual reduction strategy or upstream approach is the UK voluntary salt reduction programme implemented by the Food Standards Agency (FSA), a non-ministerial government department. This programme was aimed at getting the food industry to gradually decrease the quantity of salt added to processed food over the past decade.13 Incremental salt reduction targets were set, with a clear timeframe for the food industry to reach them, and the population salt intake was reduced by 15%.13 The reduction in salt intake was likely associated with decreases in the population blood pressure.29 Much of this reduction has been achieved through partnership with industry to set voluntary reformulation targets.13 In addition to this, reducing salt intake through voluntary reformulation and increasing public awareness has been a highly cost-effective policy option. Voluntary recommendations also allowed the FSA to advocate for the highest reduction possible, instead of setting only maximum targets, which would have been the case if these were set in legislation.30 Regarding free sugars, a modelling study revealed that an incremental reduction in free sugars added to SSBs without the use of artificial sweeteners is predicted to reduce the prevalence of overweight, obesity and type 2 diabetes.7 These findings suggest that this innovative strategy for the gradual and stepwise reduction of free sugars might lead to an effective and sustainable reduction of energy intake and body weight in the population.7 Our gradual free sugar reduction strategy in Austria was carried out by a small non-profit and non-governmental organization. In 2012, the beverage industry started responding to the beverage checklist. Furthermore, by 2014, there was a higher media presence, and in 2016, a mobile app was developed with regard to the public health strategy. We believe that by continuing our work, it will be possible to get the industry to voluntarily reformulate their products, and voluntary agreements might be able to push the industry to go beyond ‘business as usual’. Furthermore, successful voluntary agreements require early involvement of a wide range of stakeholders for pledge targets to be meaningful.31 However, the greatest risk involved in a voluntary approach is designing a scheme which is too complex and causes businesses to disengage with the process or, in contrast, establishing targets which are easily achievable but fail to deliver the policy objectives.30 There is also evidence that various countries have already established and implemented approaches focusing on the reduction of SSB intake by, for example, limiting their availability, increasing marketing price, raising public awareness through education programmes by media and school, tax policies and clear labelling.7 Action is needed across all policy domains––the food environment, food system and behaviour change communication––as each plays an important role in influencing what we consume.32 Studies have now shown that the purchase of SSBs is decreasing in countries following the introduction of taxes on SSBs, e.g. in Mexico,33 with a greater reduction in 2015 compared to 2014. The absolute and relative reductions in Mexico were the highest among households at lower socioeconomic levels.33 However, there is, to date, no evidence that the tax on SSBs in Mexico has had any impact on levels of obesity. Finally, we believe that voluntary gradual free sugar reduction by the beverage industry to tackle obesity and non-communicable diseases will be part of the solution with the greatest public health impact. Changes in consumers’ preferences regarding flavour and sweet taste might also be possible and could occur after reformulation. However, reformulation strategies are expected to take time to implement and will happen gradually. Moreover, we think that in addition to the beverage checklist to inform consumer choice, we do also need even more political pressure to ensure compliance to reformulation or free sugar reduction. This could be reinforced by media campaigns or by guidelines to the catering sector, e.g. school cafeterias, which was also part of our public health strategy. Mandatory reformulation might thus be more effective than voluntary reformulation. Reducing the free sugar content in sugary drinks appears to be effective and, thus, is a ripe target for regulation. In the coming years, we will gradually reduce the guiding criterion to a maximum of 6 g free sugars/100 ml. Finally, multi-component interventions appear to be more effective than single interventions.34 Limitations The study has several limitations. Firstly, the beverage checklist’s guiding criterion of a free sugar content of ≤7.4 g free sugars/100 ml is based on the WHO recommendation.17 The calculation of this cut-off is based on adolescents’ total energy expenditure, on the consideration of 0.5 l SSB and of a tolerance range of 25%. This cut-off value differs from other recommendations, such as the guidelines of the UK Department of Health and the FSA24 and/or the announced UK SSB tax.35 However, adolescents, our initial target group, and the whole population need to get accustomed to the reduced free sugar content in beverages and the beverage industry also needs time to adapt. Therefore, a tolerance range of 25% seemed appropriate. However, we intend to reduce this tolerance range in the near future. The second limitation in this study is that it might be possible that some beverages were unintentionally excluded, as the beverage checklist is a comprehensive survey of all beverages available in a snapshot in time of every year, using one large outlet in at least three out of nine federal states per each of the four main supermarket chains, which together hold 88% of the grocery market share in Austria. Due to this fact, since 2012, all known beverage producers were asked to add their products to the beverage checklist. However, at the beginning of this approach, the response rate of the industry was low, but then increased until 2017. The third limitation might be that specific isotonic sports and energy drinks serve only as an addendum to the beverage checklist, and this addendum cannot be considered as a complete list of these specific beverages on sale in Austria. Furthermore, these types of beverages were not the initial focus of the beverage checklist, and according to the Austrian Association of Beverage Manufacturers, the percentage of the market was only 11% in 2016.30 However, to the best of our knowledge, this is the first study assessing free sugar content over a certain time period and giving implications for further public health initiatives to tackle obesity. Conclusions In conclusion, the beverage checklist, as a public health strategy, reduced the free sugar content in SSBs by working with the industry to reformulate beverages with less free sugars on a voluntary basis. Hence, more beverages with less added sugars were brought to the market, which implies healthier choices for consumers and the whole population. The challenge now is to further engage the industry and also policy makers to achieve a greater reduction in the future, and also to implement a consumer awareness campaign. Acknowledgement The authors would also like to thank Mark Ackerley for the professional proofreading. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. Conflicts of interest: None declared. Key points We investigated the free sugar content in SSBs over a certain time period and suggest implications for further public health initiatives to tackle obesity. The free sugar content in SSBs decreased due to working with the industry, as they brought more beverages with less added sugars to the market, which implies healthier choices for the population. As this gradual sugar reduction strategy was carried out by a small non-profit organization, an even greater reduction could be achieved in the future by bringing it to the policy-making level. References 1 Malik VS, Pan A, Willett WC, Hu FB. Sugar-sweetened beverages and weight gain in children and adults: a systematic review and meta-analysis. Am J Clin Nutr  2013; 98: 1084– 102. Google Scholar CrossRef Search ADS PubMed  2 Te Morenga L, Mallard S, Mann J. Dietary sugars and body weight: systematic review and meta-analyses of randomised controlled trials and cohort studies. BMJ  2012; 346: e7492. Google Scholar CrossRef Search ADS PubMed  3 Greenwood DC, Threapleton DE, Evans CE, et al.   Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose-response meta-analysis of prospective studies. Br J Nutr  2014; 112: 725– 34. Google Scholar CrossRef Search ADS PubMed  4 Marshall TA, Levy SM, Broffitt B, et al.   Dental caries and beverage consumption in young children. Pediatrics  2003; 112: e184– 91. Google Scholar CrossRef Search ADS PubMed  5 Wilder JR, Kaste LM, Handler A, et al.   The association between sugar-sweetened beverages and dental caries among third-grade students in Georgia. J Public Health Dent  2016; 76: 76– 84. Google Scholar CrossRef Search ADS PubMed  6 Lobstein T. Available at: http://www.who.int/elena/titles/commentary/ssbs_childhood_obesity/en/ (5 May 2017, date last accessed). 7 Ma Y, He FJ, Yin Y, et al.   Gradual reduction of sugar in soft drinks without substitution as a strategy to reduce overweight, obesity, and type 2 diabetes: a modelling study. Lancet Diabetes Endocrinol  2016; 4: 105– 14. Google Scholar CrossRef Search ADS PubMed  8 Singh GM, Micha R, Khatibzadeh S, et al.   Global, regional, and national consumption of sugar-sweetened beverages, fruit juices, and milk: a systematic assessment of beverage intake in 187 countries. PLoS One  2015; 10: e0124845. Google Scholar CrossRef Search ADS PubMed  9 World Health Organization. Available at: http://www.who.int/elena/bbc/ssbs_adult_weight/en/ (15 January 2016, date last accessed). 10 Popkin BM, Hawkes C. Sweetening of the global diet, particularly beverages: patterns, trends, and policy responses. Lancet Diabetes Endocrinol  2016; 4: 174– 86. Google Scholar CrossRef Search ADS PubMed  11 Duffey KJ, Huybrechts I, Mouratidou T, et al.   Beverage consumption among European adolescents in the HELENA study. Eur J Clin Nutr  2012; 66: 244– 52. Google Scholar CrossRef Search ADS PubMed  12 Singh GM, Micha R, Khatibzadeh S, et al.   Estimated global, regional, and national disease burdens related to sugar-sweetened beverage consumption in 2010. Circulation  2015; 132: 639– 66. Google Scholar CrossRef Search ADS PubMed  13 He FJ, Brinsden HC, MacGregor GA. Salt reduction in the United Kingdom: a successful experiment in public health. J Hum Hypertens  2014; 28: 345– 52. Google Scholar CrossRef Search ADS PubMed  14 Mennella JA. Ontogeny of taste preferences: basic biology and implications for health. Am J Clin Nutr  2014; 99: 704S– 11S. Google Scholar CrossRef Search ADS PubMed  15 Hashem KM, He FJ, Jenner KH, MacGregor GA. Cross-sectional survey of the amount of free sugars and calories in carbonated sugar-sweetened beverages on sale in the UK. BMJ Open  2016; 6: e010874. Google Scholar CrossRef Search ADS PubMed  16 Codex Alimentarius Austriacus (IV. Edition). Available at: http://www.lebensmittelbuch.at/erfrischungsgetraenke/energie-getraenke-energy-drinks/ (16 January 2018, date last accessed). 17 World Health Organization (WHO). Diet, Nutrition and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation . Geneva: World Health Organization (WHO), 2003. Contract No.: No. 916. 18 German Nutrition Society (DGE), Austrian Nutrition Society (ÖGE), Swiss Nutrition Society (SGE). Energie. D-A-CH-Referenzwerte für die Nährstoffzufuhr. Neustadt a. d. Weinstraß: Neuer Umschau Buchverlag, 2008. 19 World Health Organization. Sugars Intake for Adults and Children. Guideline . Geneva: World Health Organization, 2015: 49. 20 Swithers SE, Martin AA, Davidson TL. High-intensity sweeteners and energy balance. Physiol Behav  2010; 100: 55– 62. Google Scholar CrossRef Search ADS PubMed  21 Bosetti C, Gallus S, Talamini R, et al.   Artificial sweeteners and the risk of gastric, pancreatic, and endometrial cancers in Italy. Cancer Epidemiol Biomarkers Prev  2009; 18: 2235– 8. Google Scholar CrossRef Search ADS   22 Austrian Federal Ministry of Health. Available at: https://www.bmgf.gv.at/cms/home/attachments/6/4/0/CH1047/CMS1313558884746/leitlinie_schulbuffet_20150619.pdf (12 June 2017, date last accessed). 23 Cash Pocket. Available at: http://www.cash.at/uploads/media/CASH_Pocket_0215.pdf (8 May 2017, date last accessed). 24 Department of Health, Food Standards Agency. Available at: https://www.food.gov.uk/sites/default/files/multimedia/pdfs/pdf-ni/fop-guidance.pdf (15 May 2017, date last accessed). 25 Austrian Agency for Health and Food Safety (AGES). Available at: https://www.ages.at/en/topics/nutrition/the-austrian-food-pyramid/# (16 January 2018, date last accessed). 26 Kazemi E, Hosseini SM, Bahrampour A, et al.   Predicting of trend of hemoglobin a1c in type 2 diabetes: a longitudinal linear mixed model. Int J Prev Med  2014; 5: 1274– 80. Google Scholar PubMed  27 Hill JO. Can a small-changes approach help address the obesity epidemic? A report of the Joint Task Force of the American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. Am J Clin Nutr  2009; 89: 477– 84. Google Scholar CrossRef Search ADS PubMed  28 Buttriss JL, Welch AA, Kearney JM, Lanham-New SA. In: Sons JW, editor. Public Health Nutrition . UK: Wiley-Blackwell, 2017: 456. 29 He FJ, Pombo-Rodrigues S, Macgregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open  2014; 4: e004549. Google Scholar CrossRef Search ADS PubMed  30 Austrian Association of Beverage Manufacturers. Available at: http://getraenkeverband.at/limonade/zahlen-und-daten/1641-oesterreichischer-limonadenmarkt-2016.html (16 January 2018, date last accessed). 31 Bryden A, Petticrew M, Mays N, et al.   Voluntary agreements between government and business–a scoping review of the literature with specific reference to the Public Health Responsibility Deal. Health Policy  2013; 110: 186– 97. Google Scholar CrossRef Search ADS PubMed  32 World Cancer Research Fund International. Available at: http://www.wcrf.org/sites/default/files/Curbing-Global-Sugar-Consumption.pdf (31 May 2017, date last accessed). 33 Colchero MA, Popkin BM, Rivera JA, Ng SW. Beverage purchases from stores in Mexico under the excise tax on sugar sweetened beverages: observational study. BMJ  2016; 352: h6704. Google Scholar CrossRef Search ADS PubMed  34 Hyseni L, Atkinson M, Bromley H, et al.   The effects of policy actions to improve population dietary patterns and prevent diet-related non-communicable diseases: scoping review. Eur J Clin Nutr  2017; 71: 694– 711. Google Scholar CrossRef Search ADS PubMed  35 UK government. Available at: https://www.gov.uk/government/publications/soft-drinks-industry-levy/soft-drinks-industry-levy (16 January 2018, date last accessed). © The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

The European Journal of Public HealthOxford University Press

Published: Mar 15, 2018

There are no references for this article.

You’re reading a free preview. Subscribe to read the entire article.


DeepDyve is your
personal research library

It’s your single place to instantly
discover and read the research
that matters to you.

Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.

All for just $49/month

Explore the DeepDyve Library

Search

Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly

Organize

Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.

Access

Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.

Your journals are on DeepDyve

Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.

All the latest content is available, no embargo periods.

See the journals in your area

DeepDyve

Freelancer

DeepDyve

Pro

Price

FREE

$49/month
$360/year

Save searches from
Google Scholar,
PubMed

Create lists to
organize your research

Export lists, citations

Read DeepDyve articles

Abstract access only

Unlimited access to over
18 million full-text articles

Print

20 pages / month

PDF Discount

20% off