Environmental interventions to reduce the consumption of sugar-sweetened beverages and their effects on health

Abstract

BackgroundFrequent consumption of excess amounts of sugar‐sweetened beverages (SSB) is a risk factor for obesity, type 2 diabetes, cardiovascular disease and dental caries. Environmental interventions, i.e. interventions that alter the physical or social environment in which individuals make beverage choices, have been advocated as a means to reduce the consumption of SSB.ObjectivesTo assess the effects of environmental interventions (excluding taxation) on the consumption of sugar‐sweetened beverages and sugar‐sweetened milk, diet‐related anthropometric measures and health outcomes, and on any reported unintended consequences or adverse outcomes.Search methodsWe searched 11 general, specialist and regional databases from inception to 24 January 2018. We also searched trial registers, reference lists and citations, scanned websites of relevant organisations, and contacted study authors.Selection criteriaWe included studies on interventions implemented at an environmental level, reporting effects on direct or indirect measures of SSB intake, diet‐related anthropometric measures and health outcomes, or any reported adverse outcome. We included randomised controlled trials (RCTs), non‐randomised controlled trials (NRCTs), controlled before‐after (CBA) and interrupted‐time‐series (ITS) studies, implemented in real‐world settings with a combined length of intervention and follow‐up of at least 12 weeks and at least 20 individuals in each of the intervention and control groups. We excluded studies in which participants were administered SSB as part of clinical trials, and multicomponent interventions which did not report SSB‐specific outcome data. We excluded studies on the taxation of SSB, as these are the subject of a separate Cochrane Review.Data collection and analysisTwo review authors independently screened studies for inclusion, extracted data and assessed the risks of bias of included studies. We classified interventions according to the NOURISHING framework, and synthesised results narratively and conducted meta‐analyses for two outcomes relating to two intervention types. We assessed our confidence in the certainty of effect estimates with the GRADE framework as very low, low, moderate or high, and presented ‘Summary of findings’ tables.Main resultsWe identified 14,488 unique records, and assessed 1030 in full text for eligibility. We found 58 studies meeting our inclusion criteria, including 22 RCTs, 3 NRCTs, 14 CBA studies, and 19 ITS studies, with a total of 1,180,096 participants. The median length of follow‐up was 10 months. The studies included children, teenagers and adults, and were implemented in a variety of settings, including schools, retailing and food service establishments. We judged most studies to be at high or unclear risk of bias in at least one domain, and most studies used non‐randomised designs. The studies examine a broad range of interventions, and we present results for these separately.Labelling interventions (8 studies): We found moderate‐certainty evidence that traffic‐light labelli...

What should governments be doing to prevent diabetes throughout the life course?

“…Such interventions should be initiated early in pregnancy and continue throughout the pregnancy, as major short-and long-term health consequences for both the mother and the child are likely. • Develop and implement national diabetes plans as well as regional strategies promoting local partnerships with communities and stakeholders [38] • Governments should support the implementation of interdisciplinary care teams, with special regard to the involvement of pharmacists [39] • Improve the transparency of product ingredients using mandatory simple and intuitive nutrition or menu labelling [40] • Set up government food benefit programmes to incentivise the purchase of fruit and vegetables [41] • Support the certification of digital devices and apps to improve access to evidencebased health information [42] • Use narrative and visual messages to improve diabetes awareness [43] • Support interpretative nutrition labelling, like traffic lights, to decrease SSB sales [41] • Strengthen the framing of diabetes as a problem to be tackled on the societal level [44] • Raise taxes on unhealthy products (and consider the liability for adverse health effects of food and beverage products) and reinvest the money in local infrastructure (outdoor gyms and playgrounds) [45] Pregnant women and young families • Screen high-risk groups (elevated risk due to family history, increased BMI) for early detection of GDM [46] as a precondition for lifestyle change • Give advice regarding healthy eating and set activity targets during pregnancy [47,48] • Give advice regarding the benefits of breastfeeding [49] • Employ multimedia communication strategies to increase the widespread knowledge of diabetes risk during pregnancy [50,51] Children and adolescents…”

“…• Set minimum standards for break times and outdoor equipment to increase physical activity levels [52] • Include a health subject called 'health' in (pre-) schools and continuously qualify the teachers [38] • Provide drinking water and low-cost/ free-of-charge healthy food [53] • Cooperate with local sports clubs in designing break time activities, physical activity lessons and afternoon care [54] • Improve access to eHealth devices for diabetes self-management [55] • Restrict advertisement of unhealthy food choices across the media spectrum [41,56] • Publicity intervention to increase awareness to promote earlier diagnosis of type 1 diabetes [57] • Implement binding quality standards and healthy food procurement for the catering tenders in (pre-)schools [41] • Restrict the advertisement of unhealthy products [41,54,56] • Implement fat and/or sugar taxes [56] and/or set smaller prices for healthier beverages (especially at school) [41] Working-age population • Implement the structured, evidence-based curricula like the Diabetes Prevention Program (DPP) [58] and monitor their effectiveness in different settings and target groups [59] • Include community awareness campaigning in national chronic disease and/or diabetes plans [61] • Offer (tax) subvention for companies who actively support their employees' health and support companies to develop and implement measures of operational health management [58] • Improve access to eHealth devices for diabetes self-management [55] • Include workplace interventions for individuals at risk [61] • Offer subvention of healthy food procurement for companies [59] Elderly • Develop structured care programmes, and increase frequency of educational sessions [62,63] • Continuously monitor the enrolment rates in interventions and effectiveness for specific subgroups of the population [64] • Strengthen eHealth literacy to increase access to digital health information [65] • Reduce or eliminate out-of-pocket costs for diabetes medication and self-monitoring supplies [66] The Interventions should, according to the authors, include regular counselling on dietary behaviour, such as the composition of a healthy meal (not more than 75...…”

“…A recent Cochrane systematic review found existing effective and scalable interventions to reduce SSB consumption on a population-based level. Moderate certainty evidence was found for interpretative nutrition labelling (traffic lights), economic tools (price increases on SSBs), multicomponent community campaigns, and home-based interventions (home deliveries of diet beverages and bottled water) [41]. Another systematic review revealed that school district SSB policies and school food and nutrition policies can be effective in changing dietary habits [53].…”

Klug entscheiden – Perspektiven: Was sind die entscheidenden Ansätze (Key Questions) für die Zukunft?

“…Der Verkauf ungesunder, zuckerund kaloriendichter Nahrungsmittel kann nur durch politische Maßnahmen gegenüber den Nahrungsmittelherstellern reguliert werden. Aus der Vergangenheit wissen wir, dass nicht durch freiwillige, sondern nur durch fiskalpolitisch unterlegte Vorgaben die Industrie zu einer wirksamen Reduzierung des Zuckergehalts hochverarbeiteter Nahrungsmittel und Softdrinks gebracht werden kann [63,64]. KEE sollten sich dieses zentralen Themas annehmen, da es erhebliche Ressourcen des Gesundheitssystem verbrauchen wird, wenn über 50 % der Bevölkerung an einer Adipositas leiden werden [59].…”

Süßgetränke und Körpergewicht: Zusammenhänge und Interventionsmöglichkeiten

“…Diese lassen sich grundsätzlich alle auch für die Reduktion der gesundheitlichen Risiken des Süßgetränkekonsums einsetzen (Tab. 1) (36,37). Besonders große Aufmerksamkeit haben in der politischen Diskussion zuletzt drei dieser Interventionstypen erfahren: Süßgetränkesteuern, Werbebeschränkungen und Veränderungen des Getränkeangebots in Schulen und Kindergärten.…”