A new study published in the Journal of Public Health Research has found that in South Africa, sugar-sweetened beverage manufacturers spent USD 191 million (ZAR 3.7 billion) advertising SSBs across different media from 2013 to 2019. The bulk of this was spent on television (TV) advertising, particularly during children’s and family viewing times.

Researchers from PRICELESS South Africa, the SAMRC Centre for Health Economics and Decision Science at the University of Witwatersrand, and UNC-Chapel Hill measured the number of sugary beverage advertisements in South Africa from January 2013 to April 2019. They used Nielsen data from the top 10 manufacturers in South Africa to assess advertising expenditures across different media, including TV, print newspapers and magazines, radio, and internet. They examined data by drink category and media type and analyzed the number of ads aired on TV during child and family peak viewing times (between 3 p.m. and 7 p.m. on weekdays).

Key findings:

• Beverage manufacturers spent USD 191 million (ZAR 3.7 billion) to advertise SSBs during this 6-year period. This sum was largely spent their marketing sugary drinks in TV ads, particularly during child and family viewing time (between 3 and 7 p.m.).

• Between 2013 and 2019, spending on NCD prevention by South Africa’s National Department of Health was 7.1% of what Coca-Cola spent on SSB ads.

• Manufacturers increased their advertising expenditures after the announcement of the Health Promotion Levy in June 2016 (a tax on sugary drinks), however the HPL was still effective in reducing consumption of taxed beverages.

South Africa faces high levels of diet-related diseases such as obesity, type 2 diabetes, hypertension, cardiovascular disease, and cancer. Drinking excess sugary drinks increases the risk of developing these diseases and their risk factors. Research shows that marketing and advertising is a key factor in promoting the consumption of sugary drinks and other ultra-processed products and that children and adolescents are highly susceptible to food marketing.

To lower consumption of sugary drinks as well as foods high in sugar, salt, saturated fat, South Africa implemented a sugary drink tax in 2018 that has already led to decreased purchases and intake of sugary drinks. The country also recently issued a draft regulation for mandatory front-of-package warning labels, which includes a stipulation that products with warning labels (i.e., high in salt, fat, sugar, or containing artificial sweeteners) may not use certain marketing techniques on their packages.

Thus far, however, the country has not enacted policies to restrict marketing of non-essential foods or drinks beyond the proposed packaging restrictions. This study suggests that the sweetened beverage industry is capitalizing on the child and family market, particularly via television advertising. The study also finds that industry’s voluntary pledges to curb marketing aimed at children have not worked, further underscoring the need for statutory action.

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This research was funded by Bloomberg Philanthropies and the South African Medical Research Council.

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Two recent studies conducted by researchers from the Global Food Research Program at UNC-Chapel Hill and the University of Chile have found that in the first phase of Chile’s Law of Food Labeling and Advertising, consumers’ beverage purchases contained less sugar and more non-nutritive sweeteners (e.g., Aspartame, Stevia, or Sucralose), but overall beverage sweetness stayed the same.

The requirement under Chile’s law for products high in calories or added sugar, salt, saturated fat to carry a front-of-package warning label has prompted the food and beverage industry to reformulate and introduce new products in order to avoid regulation. For example, companies have reduced the amount of added sugars in drinks to fall below the law’s sugar threshold, while replacing some of that sugar with non-nutritive sweeteners to maintain a similar taste. One study found that the share of beverages in Chile containing non-nutritive sweeteners increased by more than 10% after the law came into effect.

Taste test: beverage sweetness

In a study published in Frontiers in Nutrition in October 2022, researchers found that Chile’s policies were not associated with changes in overall sweetness taste of the beverages consumers bought, despite evidence of product reformulation to contain less sugars and more non-nutritive sweeteners (which can taste 10–20,000 times sweeter than sugars).

“We wanted to look at overall change in sweetness to understand what consumers were being exposed to, as a result of reformulation,” said Natalia Rebolledo, postdoctoral researcher at the Center for Research in Food Environments and Prevention of Nutrition-Related Chronic Diseases (CIAPEC) at the University of Chile and the study’s first author. “We focused on beverages because they are the main dietary source of added sugars and non-nutritive sweeteners in the Chilean diet.”

For this study, researchers analyzed the weekly grocery purchases of over 2,000 households before and after the labeling law began and evaluated the total sweetness of purchases. They did this by creating a “sweetness index” to measure and compare levels of non-nutritive sweeteners, total sugars, and total combined sweetness in each beverage purchased, taking into account the unique levels of sweetness tastes from non-nutritive sweeteners and sugars. The team used data from the Chilean Nutritional Facts Panel, which provided the actual amounts of total sugars and non-nutritive sweeteners included in the drinks purchased by study households.

Key findings during Phase 1 of the law:

• Total sweetness of the beverages purchased by consumers did not change: Sweetness from non-nutritive sweeteners increased but was offset by less sweetness from sugars. This indicates that companies likely aimed to keep their products as similar as possible to the original taste profile.

• Sugars are still the main source of sweetness for beverages, contributing 59% of total sweetness measured.

• Researchers observed no differences in sweetness consumption by household education level, assets, or presence of children in the home.

This is the first study to analyze whether beverage sweetness changed based on the type of sweetener used (sugars and/or non-nutritive sweeteners) after the implementation of the Law of Food Labeling and Advertising in Chile.

Sweetener purchases

The team’s next study, published in Current Developments in Nutrition in December 2022, examined changes in purchases of foods and beverages sweetened with non-nutritive and caloric sweeteners after Phase 1 of the law.

Using the same dataset of weekly grocery purchases from over 2,000 households, researchers analyzed the sweetener content of purchased foods and beverages before and after the labeling and marketing law began. They created four product categories based on the types and combination of sweeteners used in each product purchased:

1. No added sweeteners used;
2. Caloric sweeteners used, but no non-nutritive sweeteners used;
3. Non-nutritive sweeteners used, but no caloric sweeteners used; and
4. Both caloric and non-nutritive sweeteners used.

Researchers then analyzed products purchased products in each category before and after the law.

Key findings during Phase 1 of the law:

• Percent of households that purchased beverages sweetened with any non-nutritive sweeteners increased 4.2 percentage points (from 88% of households to 92.2%), driven mostly by an increase in households buying drinks containing only non-nutritive sweeteners (52.4% of households to 64.5%).

• The proportion of households purchasing beverages with only caloric sweeteners dropped 6 percentage points (from 92% of households to 86%). This indicates that households substituted some caloric beverages with beverages containing some amount of non-nutritive sweeteners.

• The daily purchase volume of beverages sweetened with any non-nutritive sweetener increased by 25 mL per person, or roughly 27%. Most of this increase was from households buying more drinks containing both non-nutritive and caloric sweeteners (increased 17 mL per person per day).

• Households bought 17% less unsweetened beverages, by volume (–31 mL per person per day), and the proportion of study households that purchased any unsweetened beverages dropped 2%.

• The authors found minimal changes in sweetener purchases from foods, possibly due to the more strict thresholds in the law for sweeteners in beverages compared to foods.

This is the first study to analyze the change in purchases of sweeteners in food and beverages after the implementation of the Law of Food Labeling and Advertising in Chile.

Both of these studies add to previous research evaluating the impact of Chile’s Law of Food Labeling and Advertising on intake, including a study from the same research team finding that preschoolers increased their non-nutritive sweeteners intake by 14 percentage points in the first year of the law.

Rebolledo says of their findings, “It is positive that beverages did not get sweeter as a result of higher non-nutritive sweetener use. It appears that both the beverage industry and consumers are substituting caloric sweeteners with non-nutritive sweeteners, which could have long-term health impacts that we need to better understand. We need to continue monitoring the following phases of the law to see if Chileans changed their purchasing habits after the requirements for warning labels and marketing became stricter.”

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This research was funded by Bloomberg Philanthropies, National Institutes of Health, National Commission for Scientific and Technological Research (CONICYT), and Becas Chile Doctorado 2017.

AUTHORS

Natalia Rebolledo
Maxime Bercholz
Linda Adair
Camila Corvalán
Shu Wen Ng
Lindsey Smith Taillie

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What are non-nutritive sweeteners?

Non-nutritive sweeteners are sweeteners that have intensely sweet taste and typically do not contribute calories or are very low in calories. Non-nutritive sweeteners can be naturally occurring/derived from plants (e.g., sorbitol, xylitol, erythritol, stevia glycosides, monk fruit extract) or synthetic/”artificial” (e.g., aspartame, saccharin, sucralose, or acesulfame potassium).

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FACT SHEETS

Read more about the evidence for front-of-package labels and marketing restrictions.

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Learn more about Chile’s policies and our evaluation work there.

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Parents are more likely to choose a fruit drink with added sugar for their young child when the drink’s packaging includes nutrition-related claims, researchers with the Global Food Research Program found in a study published in the American Journal of Clinical Nutrition.

This study is among the first to look at how claims influence parents’ drink purchases for their young child (ages 1-5).

In their experiment, the research team invited parents to “shop” in a virtual convenience “store” (similar to a video game, right) on participants’ own computers. The study’s 2,219 participants were randomly assigned to view fruit drinks displaying one of three claims (“No artificial sweeteners,” “100% Vitamin C,” or “100% All Natural”) or no claim.

Findings

The research team found that healthful claims increased misperceptions about nutritional quality. Even though all drink labels also contained nutritional panel information, parents who viewed drinks with claims were more likely to incorrectly believe that the fruit drinks did not contain added sugar or were 100% juice.

“Parents who saw the claims were more likely to pick the sugary fruit drink instead of water, as well as choose the sugary fruit drink instead of 100% fruit juice,” said Marissa Hall, assistant professor at UNC-Chapel Hill’s Gillings School of Global Public Health and the study’s lead author. “The sugary fruit drinks had over 30 grams of added sugar, and that information was right there on the label. But still, the presence of a claim made parents more likely to think that the sugary fruit drinks did not have any added sugar. Also, the claims made parents think that the drinks were 100% fruit juice, which was not the case.”

“The sugary fruit drinks had over 30 grams of added sugar, and that information was right there on the label. But still, the presence of a claim made parents more likely to think that the sugary fruit drinks did not have any added sugar.“

— Marissa Hall, PhD

These findings build on the authors’ research looking at how often nutrition-related claims appear on fruit drinks and how claims relate to drinks’ actual nutritional profile. They have also examined sociodemographic disparities between households that purchase fruit drinks with claims (under review). Key findings from these studies include:

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  Nutrition-related claims are ubiquitous: 97% of fruit drinks purchased had at least one and, on average, 3 to 4 nutrition-related claims on the front-of-package.
• Fruit drinks with claims related to vitamin C, juice or nectar, fruit or fruit flavor, and “natural” claims were higher in calories and sugar than fruit drinks without these claims.
• Less than a quarter of fruit drinks studied listed juice in their top two ingredients, but over half had juice, nectar, or fruit claims on the front of the package.
• U.S. households with infants and young children from socially disadvantaged groups were more likely to purchase fruit drinks.

Implications

Collectively, these studies’ findings suggest a need for stronger regulation of marketing claims on fruit drinks.

“Claims can make products seem healthier to parents than they really are,” said Lindsey Smith Taillie, PhD, senior author and assistant professor at Gillings School of Global Public Health. “This is problematic and important from a policy standpoint.”

“The FDA could consider requiring nutrient warning labels or disclaimers on the products to help inform consumers about the risk, or regulating use of certain claim types,” said Hall. “For example, the FDA could prohibit labeling a sugary fruit drink ‘all natural,’ if it contains above a certain amount of added sugar.”

Taillie notes that a precedent for such policies exists in other countries. “In Mexico, for example, beverages that are high in sugar are prohibited from carrying nutrition claims. This type of regulation could help make it easier for parents to be able to quickly and easily sort out the sugary drinks from the healthier options while grocery shopping.”

“The FDA has broad authority to combat deceptive labeling,” said Eva Greenthal, co-author and senior science policy associate at the public health advocacy group, Center for Science in the Public Interest. “The agency should consider requiring nutrient warnings on products that are high in added sugars, requiring more prominent ‘percent juice’ declarations on fruit drink labels, and prohibiting nutrient claims like ‘100% Vitamin C’ on beverages that are high in added sugars.”

Read more about these studies and their findings in our Fruit Drinks Study Series infographic fact sheet.

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This research was supported by grant #76337 from the Robert Wood Johnson Foundation’s Healthy Eating Research program.

AUTHORS:

Marissa G Hall
Allison J Lazard
Isabella CA Higgins
Jonathan L Blitstein
Emily W Duffy
Eva Greenthal
Sarah Sorscher
Lindsey Smith Taillie

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RESOURCES:

Learn more about the team’s findings on fruit drink claims in our fruit drinks fact sheet.

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Multiple countries have enacted policies to help reduce the prevalence of sugar-sweetened beverages (SSBs) in the diet, and a new review in the Annual Review of Public Health outlines the impacts these policies are having around the world.

Shu Wen Ng, PhD, Distinguished Scholar in Public Health Nutrition at the UNC Gillings School of Global Public Health and the Global Food Research Program at UNC, is co-author of “Sugar-Sweetened Beverage Reduction Policies: Progress and Promise,” published April 1, 2021, with co-authors from the University of Washington, Harvard University and the American Heart Association.

Their review presents a framework illustrating the various types of financial, information, default and availability policies that have been used to reduce SSB exposure and consumption and introduces how considerations such as feasibility, impact and equity crosscut those policies.

Financial policies include the increase of price on SSBs, taxes, restrictions on price or promotions and incentives for the purchase of healthy beverages (e.g, plain milks and water).

• SSB taxes are one of the most effective policies for SSB reduction with seven US cities and more than 40 nations across the globe having adopted SSB taxes as of August 2020. Evidence shows that they not only increase the prices of SSBs, but they also reduce purchases of those beverage. Though opponents have claimed that these taxes result in job losses, research has not yet found this to be true.

Information policies, such as warning labels on packages or advertising restrictions, reduce the public’s exposure to SSB marketing and / or increase awareness of their health risks.

• Front-of-package warning labels on SSBs can indicate the presence and amount of harmful ingredients, like excess sugar, or describe their negative health outcomes, like type 2 diabetes, to influence consumer behavior. More than 40 countries have implemented voluntary or mandatory warning labels. A simulation study of a U.S. national mandatory SSB health warning policy found that it would reduce average SSB intake by 25.3 calories per day and total energy intake by 31.2 calories per day.

Default policies, such as including a healthy drink in kids’ restaurant meals, make the choice of a healthy beverage automatic.

• When restaurants bundle SSBs with kids’ meals or make them the default option, the likelihood of consuming SSBs when eating out increases. An analysis of kids’ meals at large U.S. chain restaurants shows that substituting a lower-calorie beverage (e.g., water) for a sugary drink in the U.S. would reduce calories in a default meal by 100 calories and 20 grams of sugar. Some restaurants have made voluntary pledges to offer healthier beverages as the default option in these meals and a handful of state and local governments in the U.S. have passed laws to improve the healthfulness of beverages in children’s meals.

Availability policies decrease access to SSBs or reduce portion sizes through beverage procurement policies or product placement of both SSBs and healthy beverages.

• Recent policy actions have limited access to SSBs in federal nutrition programs, which could affect millions of Americans. Though research on availability policies is limited, one simulation study indicated that restricting SSB purchases in SNAP (Supplemental Nutrition Assistance Program), could reduce consumption by an average of 24 calories per person per day, cutting the prevalence of obesity and diabetes over time, and save money in the long-run.

When determining which policy approach or combination of approaches is appropriate, policymakers should consider whether those choices will be equitable, impactful, and feasible given the context.

“With the pandemic and the resultant shifts in where children and adults are eating and exposed to unhealthy food marketing, emphasis on policies outside of school settings such as around digital and TV marketing may be more critical now than before,” says Ng.

The co-authors note that no single policy will reduce SSB consumption to healthy levels. Rigorous policy evaluation ­– like the work of researchers at GFRP – can support effective policies and discourage ineffective policies.

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Shu Wen Ng, PhD, Associate Professor and Distinguished Scholar in Public Health Nutrition at the UNC Gillings School of Global Public Health, is a lead author of “Changes in beverage purchases following the announcement and implementation of South Africa’s Health Promotion Levy: an observational study,” which was published April 8, 2021, in The Lancet Planetary Health. Barry Popkin, PhD, W. R. Kenan Jr. Distinguished Professor at the Gillings School, is a co-author on the paper, which was published in collaboration with partners at the University of Witwatersrand, London School of Economics, and the University of the Western Cape.

South Africa faces an increasing burden of noncommunicable diseases such as diabetes, hypertension, cardiovascular disease and cancers – diseases that research shows can be linked to increased consumption of sugar, particularly from beverages. Other countries, such as Mexico, have used policies such as taxation to successfully curb consumption of sugary beverages.

South Africa’s 2018 Health Promotion Levy, placed a tax on sugary beverages with the tax amount related to the amount of sugar. This is the first study to evaluate the impact of South Africa’s tax on sugar and caloric intake.

Researchers examined the nutritional data of over 3,000 households’ purchases before and after the tax to assess any changes in daily sugar, calories, and volume of taxed and non-taxed beverages. They found a 51% reduction in sugar, a 52% reduction in calories, and a 29% reduction in volume of beverages purchased per person per day following implementation of the tax. They also found that the relative reduction in the sugar content of taxable beverages was larger than that for volume, showing that the industry likely reformulated products.

The researchers also analyzed differences in purchasing behavior by household socioeconomic status, finding that lower socioeconomic status households had purchased more taxable beverages prior to the announcement of the tax than higher socioeconomic status households, but experienced larger reductions after the announcement and implementation of the tax.

“These results back up the impact we’ve seen from similar policies in other countries – that beverage taxes based on sugar content can help reduce excessive sugar and energy intake. Importantly, this shows that the lower income households that experience the greater burden of obesity, diabetes, hypertension, and other nutrition-related noncommunicable diseases, benefit greatly from this law,” says Ng.

“Consistent with evaluations in other countries with SSB taxes, we found that taxing sugary drinks are one an effective public health strategy to reduce the burden of health conditions linked to overconsumption of sugar” noted Popkin.

Ng and Popkin are part of the Global Food Research Program at UNC, a project of the Carolina Population Center that collaborates with partners across the globe to carefully evaluate food and nutrition policies and help to develop in-depth, longitudinal research on large-scale obesity prevention efforts.

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The team examined the self-reported soft-drink intake of participants in the three phases of Mexico’s Health Workers Cohort Study – a self-administered survey on health and lifestyle choices – and announced their findings May 6, 2020, in the British Medical Journal.

Shu Wen Ng, PhD, associate professor and distinguished scholar in public health nutrition at the UNC Gillings School of Global Public Health, is coauthor of the paper, “Association between tax on sugar sweetened beverages and soft drink consumption in adults in Mexico: open cohort longitudinal analysis of Health Workers Cohort Study.”

This research is based on work conducted at the National Institute of Public Health in Mexico, with the institute’s Luz María Sánchez-Romero, MD, PhD, as first author and Tonatiuh Barrientos-Gutiérrez, MD, PhD, as senior author.

“These results show that the tax is lowering the consumption of sugar-sweetened drinks among an adult cohort over the first three-years of the tax implementation,” says Ng. “In particular, it lowered the proportion of medium and high consumers of the beverages, while increasing the share of adults who were low-consumers and non-consumers.”

Based on soft-drink consumption, researchers categorized study participants in four groups: non-consumer, low consumer (less than one serving a week), medium consumer (at least one serving a week but less than one serving a day), and high consumer (at least one serving a day). Since the tax, the probability of being a non-consumer of soft drinks increased by 4.7 percentage points, and the probability of being a medium or high consumer of soft drinks decreased by 6.8 percentage points and 6.1 percentage, respectively.

Though these results reflect just one sample of the nation’s adults, they suggest that the implementation of this tax worked in the way the Mexican government intended it to – increasing the number of individuals who do not consume soft drinks while decreasing the numbers of those who do. The findings confirm the results of earlier research that showed a decline in sugary-beverage purchases in the first two years of the tax, but this is the first study to examine self-reported consumption of the beverages in Mexico.

Sugar sweetened beverages, such as soft drinks, are a main source of added sugars in the diet, which have been linked to obesity, diabetes, cardiovascular disease and hypertension, as well as to some types of cancer. Mexico’s high mortality and morbidity rates related to sugar-sweetened beverages led lawmakers to implement a tax of 1 peso per liter on all non-alcoholic drinks with added sugar to improve health outcomes starting in Jan 2014. Since then, other nations and cities around the world have followed with their own taxes in order to reduce obesity-related diseases in their communities.

These findings are particularly timely given that the severity of and mortality from infectious diseases, including COVID-19, are heightened among those with pre-existing chronic diseases, such as those related to obesity.

“We’re beginning to see the importance and impact of these taxes over time,” says Ng. “This not only adds to the literature we have on sugar-sweetened beverages, but it also provides evidence that these policies work and motivates the need to strengthen these policies for improved health outcomes and healthcare cost savings.”

As part of UNC’s Global Food Research Program at the Carolina Population Center, Ng and her team collaborate with partners across the globe to carefully evaluate food and nutrition policies and help to develop in-depth, longitudinal research on large-scale obesity prevention efforts. Ng introduced and advised on the analytical approach used for this paper.

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Consumption of sugar-sweetened drinks dropped nearly 25 percent in the 18 months after Chile adopted a raft of regulations that included advertising restrictions on unhealthy foods, bold front-of-package warning labels and a ban on junk food in schools. During the same period, researchers recorded a five percent increase in purchases of bottled water, diet soft drinks and fruit juices without added sugar.

“An effect this big at the national level in the first year is unheard-of,” said Lindsey Smith Taillie, a nutrition epidemiologist at the University of North Carolina, Chapel Hill, and the study’s lead author. “It is a very promising sign for a set of policies that mutually reinforce one another. This is the way we need the world to go to begin to really combat preventable diseases like obesity, hypertension and diabetes.”

Read more about the regulations and our work in Chile and find the full research publication in PLOS Med.

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Connecticut may become the first state in the country to tax sugar-sweetened beverages if Gov. Ned Lamont has his way.

He’s proposed a 1.5-percent-per-ounce tax on sugary drinks, which he expects will generate $163.1 million for the Nutmeg State in fiscal 2021, which begins the preceding July,  He says it will also help residents become healthier.

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What makes this first-ever statewide effort significant is it reduces the likelihood of consumers going to neighboring areas to avoid the tax — what experts call leakage. While it’d be easy to go from a taxed city to a nearby suburb, leaving a state is a hassle.

“With a larger geographic scope of the policy, you have less opportunity for people to cross the border to do their beverage shopping,” said Shu Wen Ng, a health economist at the University of North Carolina at Chapel Hill. “For both health implications and revenue generating, a state level or larger geographical scope would be more meaningful.”

Read the full USA Today article here. View a map of sugary drink taxes around the world here.

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Juan Carlos Caro and team used data from the Colombia National Income and Expenditures Survey to estimate the price elasticities of consumer demand for sugar-sweetened beverages. They projected that a 20 percent tax on sugary beverages would decrease purchases by 32 percent and raise $480million USD in government revenue by 2020. This increased revenue could be utilized for public health projects and priorities in Colombia.

Read the full research article here or the press release from UNC here.

The Association of Schools and Programs of Public Health (ASPPH) posted a report on this study on their website on January 10, 2018, highlighting:

Obesity and overweight prevalence have increased dramatically in Colombia in recent years, and a large body of prior research makes it clear that sugar-sweetened beverages such as sodas and fruit drinks are a major contributor to these health problems.

Colombia is not alone in this. Countries around the world are implementing tax policies to reduce the consumption of sugar-sweetened beverages. Building on this momentum, a team of researchers estimated how purchases of sugar-sweetened beverages and other foods might change, as well as how government revenue might be affected, should similar fiscal measures be implemented in Colombia. (Such taxes have been discussed in the country, but have not yet been passed).

*** Post updated January 18, 2018 to reflect ASPPH report posted online.

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The study, titled Changes in Sugar-Sweetened Soda Consumption, Weight, and Waist Circumference: 2-Year Cohort of Mexican Women, found those participants who decreased their soda intake by 1+ servings each week gained less weight than those who did not change their intake. Those participants who increased their intake of soda gained more weight. This study helps to show that even small reductions in sugary drink consumption can have a positive impact on weight. Read the full article here.

In the same issue, Barry Popkin authored an editorial, titled Mexican Cohort Study Predates but Predicts the Type of Body Composition Changes Expected From the Mexican Sugar-Sweetened Beverage Tax, outlining the important lessons to be learned from Stern’s article and other studies of the Mexican sugary drink tax and related health effects. Read the editorial here.

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